
(lass XDll± 

Book K'7 

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SUBCUTANEOUS 
HYDROCARBON PROTHESES 



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A. 


Supra-Orbital Vein 


G. 


Ext. - Jugular Vein 


M. 


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B. 


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H. 


Post- Auricular " 


N. 


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1. 


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D 


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Q- 


Post, 


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Temporal 


L. 


Inf. Labial 


R. 


Sup. Coronary " 



SUBCUTANEOUS 

HYDROCARBON PROTHESES 



F. STRANGE KOLLE, M. D. 

AUTHOR OF "THE RECENT RONTGEN DISCOVERY "; "THE X-RAYS, 
THEIR PRODUCTION AND APPLICATION " ; " MEDICO- 
SURGICAL RADIOGRAPHY " ; ETC., ETC. 




THE GRAFTON PRESS 

PUBLISHERS NEW YORK 



pJBRARY of G0N6*££S» 


[wo Copies 


ieCCiv«A: 


MAY t2 


1908 


2 ^ 


iqofi 
XXc. «<* 

B. 



Copyright igo8 by 
F. STRANGE KOLLE, M. D. 



FOREWORD. 

The object of the author has been to place before the profes- 
sion a thoroughly practical and concise treatise on the subcu- 
taneous employment of hydrocarbons for the correction of de- 
fects about the face, neck and shoulders. The importance of 
this particular branch of cosmetic surgery is at the present time 
undeniable. It has revolutionized certain extensive operative 
procedures, especially in Rhinoplasty, giving results that no 
surgeon could hope to attain under the former laws of surgery. 

The literature on this subject is widely scattered and scanty. 
It consists mostly of small detached papers or reports of special 
cases by different surgeons in different countries. The author 
has selected from the most authoritative sources, such of this 
data as he deemed necessary for a full presentation of the evolve- 
ment of the methods used at present, and combined these with 
the results of his own practical experience in several thousand 
prothetic operations. 

Great care has been taken to give as faithful representation 
of the cases illustrated as possible, bearing in mind that the ac- 
tual cosmetic improvement is greater than can possibly be shown 
in black and white. 

The exponents in the text refer to the authorities given in 
the back of the book. 

F. Strange Kolle, M. D. 

18-20 West 25th Street, N. Y. 



SUBCUTANEOUS HYDROCARBON 
PROTHESES 

Although the subcutaneous employment of oil and liquefied 
paraffine has been known for some years, particularly by Corn- 
ing 1 who refers to his use of solidifying oils in surgery in an 
article published in 1891, no actual application for prothetic 
purposes was made until 1900, when Gersuny 2 first advocated 
the method. In his published report he says that, " if vaseline, 
which at the temperature of the body has the consistency of 
ointment, be liquified by heat and by the means of a Pravaz 
syringe is injected into dilatable tissue of the human body there 
is produced, at the site where the injection is made, a tumefac- 
tion whose volume corresponds to the quantity of vaseline in- 
jected. The reaction which results from the procedure is in- 
significant and the mass appears to rest without change where 
injected." 

This subcutaneous method of vaseline injection he employed 
in the case of a young girl to correct a saddle or depressed 
nose. The operation was purely a cosmetic one and was per- 
formed on the eighth day of May, 1900, with a very satisfactory 
result. 

From the time of the appearance of Gersuny' s paper, 
" Ueber eine Subcutane Prothese," a number of operators such 
as Halban, 3 von Frisch, 4 Kapsammer, 5 Delangre, 6 Rohmer, 7 
Stein 8 and others, began to follow the method with gratifying 
results. 



2 HYDROCARBON PROTHESES 

Pfannenstiel, 9 shortly after, claimed that the injection of vase- 
line was not wholly without danger and that pulmonary embo- 
lism had been observed by him subsequent to its use. Mosz- 
kowicz 10 denied the possibilities of such danger, although at this 
date it is quite evident that there are many objections to the 
sole use of sterile vaseline for all subcutaneous cosmetic pur- 
poses where such protheses might be indicated. 

Eckstein 11 on the 24th day of July, 1901, rehearses these 
objections and advocates the use of " Hart parafnne," or par- 
affine with a melting point of 57-6o°C. (i40°F.). His method 
was taken up by Broeckaert, 12 Baratoux, 13 Brindel, 14 Watson 
Cheyne, 15 Walker Downie, 16 Leonard Hill, 17 Lake, 18 Scanes 
Spicer, 19 Karewski, 20 and other prominent surgeons abroad, and 
by Parker, 21 Harmon Smith, 22 Hamilton, 23 Quinlan, 24 Connell 25 
and others in the United States. 

Drs. Lynch 26 and Heath 27 were the first American physi- 
cians to place themselves on record in the employment of the 
method of Gersuny for the correction of nasal deformities. 

Each of the operators employing the now so-called Gersuny 
method, advanced their individual ideas and improvements in 
the art, and those of distinctive merit will be considered later 
by the author who has employed both methods from the time 
of their incipiency. 

The method of procedure in the injection of vaseline or 
parafhne is practically similar, except for the various ways in 
which the paraffine of different melting points is rendered liquid. 

INDICATIONS 

The indications for the Protheses of either method are the 
same, except where the author advocates the use of either one 



HYDROCARBON PROTHESES 3 

or the other or a combination of the two from an experience 
with over five hundred personally conducted cases. 

The advantages of the Gersuny method is that the operation 
is practically painless, causes no scar if properly performed and 
corrects a deformity that could not be overcome otherwise in 
some cases, while in others it would entail not only difficult sur- 
gical interferences, but subsequently unsightly cicatrices that 
would render them more objectional than the very defects which 
were intended to be corrected. 

This is particularly true in the cosmetic correction of depres- 
sions about the forehead resulting from direct violence or frontal 
sinus operations, for obliterating habit furrows, or frowns, be- 
tween the eyebrows ; also to restore the symmetry of the 
face in hollows of the cheek due to the removal of malignant 
growths, the maxillae, or when caused by facial hemiatrophy 
or a congenital or long-acquired sinking in of the cheeks ; 
while it may also be employed with excellent result to pre- 
vent post-operative adhesions about the face after mastoid 
operations and even to restore the form of the breast after 
operation for malignant disease and the raising of smallpox 
pits. 

Numerous other uses may be mentioned, such as elevating an 
undue depression at the root of the nose, raising sunken furrows 
below the eyes, obliterating naso-labial folds, angular droops 
about the chin, rebuilding weak or pronounced oval or peaked 
chins, filling hollows about the neck and shoulders, and in fact 
anywhere about the body to restore the contour. 

In correcting the deformities of the nose, whether congenital 
or acquired, this method has met an urgent and most useful 
demand, so much so that many rhinoplastic operations of ex- 



HYDROCARBON PROTHESES 



tensive delicacy have been thrown aside for this simpler, rapid 
and gratifying means of surgery. 

Not only has it been employed to restore the nasal line in 
saddle noses, but also in many other deformities of that organ 
which do not require the removal of superabundant tissue. 

According to the appended classification of nasal deformities, 
given by Roe, 28 it will be seen that many faults of that organ 
may be overcome by the method. 



[ Concave. 
f Vertical^ 

I Convex. 
" Bony portion < > 



Deformities of 
the nose 



^ Lateral 



Spatulated. 



(^ Defected. 



r Tip «{ 



Cartilaginous 
Portion 



L Wings -^ 



Excessive or defi- 
cient tissue. 
Deviation from me- 
I dian line. 

f Collapsed. 



i Expanded. 



From the above arrangement, and taking each division sepa- 
rately, the author enumerates the applicability of the subcutane- 
ous prothesis, adding such as are not included in the above. 



i. Vertical concavity. An over-marked depression at the 
site of the bony structure and about the root of the nose. 

2. Lateral deficiency of form about the root of the nose ex- 



HYDROCARBON PROTHESES 5 

tending downward as far as the inferior borders of the nasal 
bones. 

3. Median anterior vertical concavity or saddle nose involv- 
ing the middle third, otherwise the inferior and superior sec- 
tions. 

4. Deviations of the cartilaginous structure about the middle 
third of the nose, either unilateral or bilateral. 

5. Deviation of the lobule. 

6. Deficiency of the lobule. 

7. Lobular cleft. 

8. Subseptal cleft. 

9. Collapsed alse, unilateral or bilateral. 
10. Retraction of subseptum. 

In these ten subdivisions much can be done to bring about a 
normal appearance of the nose. 

PRECAUTIONS 

In selecting a case for subcutaneous injection the operator 
must well consider the methods to be employed, his successes 
with such methods, the importance and gravity of the operation, 
the condition of the patient, the extent of the deformity, the pe- 
culiarity of the patient and, particularly, the state of mind of 
the patient. 

While at this date of the use of this method of beautifying 
parts of the human face we may feel certain of the happy out- 
come of an operation undertaken by the operator, he must not 
lose sight of the hypercritical person upon whom the work is to 
be done ; even with an outcome gratifying in the extreme from 
a surgical standpoint, the patient will insist, and that in 80$ of 



6 HYDROCARBON PROTHESES 

all cases, to still further improve them in spite of the fact that 
a normal appearance has been attained, often leading the op- 
erator into doing what he should not do, and eventually undoing 
his own excellent efforts. 

The author does not mean to imply this as a weakness on 
the part of the surgeon, but cannot impress too deeply upon 
him the unreasonable demands of a person insanely bent upon 
having the alabaster cheek ideal of the poets, the nose of a Ve- 
nus, the chin of an Apollo, the neck of swan-like form, etc. 

The patient believes it lies in the power of the cosmetic sur- 
geon to do with their malformations as a sculptor would model 
in clay and will insist upon gaining their ideal beyond all 
reason. 

Let the author warn the operator against the " beauty cranks," 
especially of those who are just about to engage in great theat- 
rical ventures, circus performances or " acts," and very desir- 
able marriages. These are patients who are not only difficult 
to deal with, but the first to harm the hard-earned, well-de- 
served reputation of the surgeon and to drag him into courts 
for reimbursement for all kinds of damages, especially backed 
up by events, losses and sufferings largely imaginable and un- 
true and ofttimes entirely impossible. 

In all cosmetic surgery this branch is the most dangerous 
from that point of view ; therefore the operator should take his 
case well in hand, proceed with an unshakable determination 
and give the patient to understand his position, even to explain- 
ing what disappointments there might be and what dangers, if 
any, he might look forward to. The author believes it no un- 
just demand to have an agreement made with the one to be 
treated in which these matters are fully considered. Such an 



HYDROCARBON PROTHESES 7 

arrangement will save him much worry and will tend in the 
majority of cases to keep his patient satisfied. 

On the other hand, the operator should not undertake to do 
an operation of a cosmetic nature unless he has a fundamental 
and practical experience of long standing in this branch of sur- 
gery and is ready at all times to cope with such post-opera- 
tive conditions as are likely to arise, which will be described 
later. 

The author has on various occasions been asked to correct 
the most hideous malformations of parts of the face, partic- 
ularly the nose, in which surgeons of high standing, both here 
and abroad, had injected paraffine in liquid form usually under 
a general anesthetic, the most remarkable being that of a hos- 
pital orderly in the U. S. Service, who had been subjected to 
not only one of such injections to correct a saddle nose under 
chloroform anesthesia, but to three distinctive operations, with 
the result of a permanent disfigurement, bettered only by a suc- 
cession of excisions at different parts of the nose. 

Apropos of such cases it may be timely to state that a gen- 
eral anesthetic for the performance of a prothetic injection 
operation is never justifiable and should be considered a lack of 
knowledge on the part of the operator, unless its use be advised 
by another surgeon in consultation. 

The greatest mistake made with this so-called " filling 
method " has been a desire on the part of the patient or the oper- 
ator, or both, to complete the work too quickly. Unscrupulous 
operators have restored a saddle nose or the contour of the 
cheeks in a few minutes, when it is an established fact that the 
work should be done slowly, giving time for the injections to 
accommodate themselves and to organize before others are 



8 HYDROCARBON PROTHESES 

attempted. This is not only true of fillings about the cheeks 
and shoulders, but also of injections about the nose and fore- 
head. 

Eschweiler 29 particularly emphasizes the advocacy of oft-re- 
peated injections, and the author recommends such rule without 
reserve or deviation. 

THE ADVANTAGE OF THE METHOD 

As has been said the advantage of the Gersuny method over 
other procedures is that it can be undertaken practically with- 
out pain, that it is quick, bloodless, leaves no scar and is harm- 
less except under good condition, as will be referred to under 
separate heading. 

While the method entails only the pain of a pin prick a local 
anesthesia may be employed to overcome this, but never a gen- 
eral anesthetic. The Ethyl Chloride spray, except at very 
small points of the skin, is not to be recommended because it 
freezes and consequently hardens the very tissue which should 
be flexible, the operation being undertaken the moment the 
needle is inserted and lasting only a few seconds. The hypo- 
dermic use of a 2% solution of cocaine, or better Eucaine fi, can 
be employed, but the author sees no advantage in it, as the 
hyperaemic engorgement following its use obliterates, to a cer- 
tain degree, the actual extent of the deformity. 

It is desirable to obtain the best result to have the skin above 
the part as free as possible. When closely adherent it should 
be freed by the careful use of a delicate tenotome, inserted at 
the point where the injection is to be made, the same opening 
being used for the introduction of the needle of the syringe. 
If this opening has been made too large a fine suture of silk should 



HYDROCARBON PROTHESES 9 

be employed to bring the lips of the wound together before the 
injection is made ; the needle point, being knife-edged, will not 
disturb the apposition and will tend to retain the filling if no 
undue pressure is used as in the case of hyperinjection. 

UNTOWARD RESULTS 

Connell 30 has tabulated the difficulties and dangers met with 
in this work as follows : 

1. Toxic absorption. 

2. Marked inflammatory reaction. 

3. Loss of tissue, due to infection and abscess formation. 

4. Pressure necrosis, caused by hyperinjection. 

5. Sloughing of tissue as a result of the heat of paraffine. 
9. Injection into very dense or inelastic structures, or where 

scar tissue is firmly attached to the underlying and 
adjacent parts. 

7. Sub-injection of too small an amount of paraffine with an 

insufficient correction of the deformity. 

8. Hyperinjection with over-correction of deformity. 

9. Air embolism. 

10. Paraffine embolism. 

1 1. Primary diffusion or extension of paraffine (when first in- 

troduced) into adjacent normal structures. 

12. Interference with muscular action of the nose. 

13. Escape of paraffine after the withdrawal of the needle or 

primary elimination. 

14. Solidification of the paraffine in the needle, which renders 

the injection difficult and causes injudicious expedition 
on the part of the operator. 

15. Absorption or disintegration of the paraffine. 



io HYDROCARBON PROTHESES 

1 6. The difficulty of procuring paraffine at the proper melt- 

ing point. 

17. Hypersensitiveness of the skin over the injected area. 

18. Redness of the skin over the injected area. 
To those the author would add : 

19. Secondary diffusion of the injected mass. 

20. Hyperplasia of the connective tissue following the organ- 

ization of the injected matter. 

21. A yellow appearance and thickening of the skin after or- 

ganization of the injected mass. 

22. The breaking down of tissue and the resulting abscess 

due to the pressure of the injected mass upon the ad- 
jacent tissue after the injection has become organized. 

Each of the above subdivisions may be advantageously con- 
sidered individually, to wit : 

1. Intoxication. — The danger of intoxication may truly be said 
to be more so due to the unclean or unsterilized matter injected 
than to the absorption following its employment, although 
Meyer 31 has claimed untoward symptoms found in his experi- 
ments from absorption of injections of vaseline in the animal. 
Taddie and Delain, 32 Stubenrath, 33 Straume, 34 Sobieranski 35 
and Dunbar 36 have corroborated this claim. They injected 
paraffine of various melting points in the lower animals and ob- 
served results therefrom, among which were loss of hair, a re- 
duction of iS% in the body weight in two months and death. 

Stein 37 and Harmon Smith 38 refute these conditions and 
remarked neither systemic nor local untoward results from 
such injections when paraffine of higher melting points were 
used. 

Jukuff 39 claims that no toxic symptoms result from the ab- 



HYDROCARBON PROTHESES n 

sorption of paraffine injected into tissues are shown, unless the 
amount be equal to 10% of the weight of the animal. To have 
this apply to the human as much as ten to fifteen pounds would 
have to be injected — an amount never required in operations 
of this nature. 

While it cannot be denied that the injected mass becomes 
more or less absorbed in from two to three months and is re- 
placed by connective tissue, it may be definitely stated that no 
toxic symptoms are caused directly thereby, except by the em- 
ployment of an impure product. 

2. Reaction. — The reaction following a properly made injec- 
tion is of a mild inflammatory character. Considerable inflam- 
mation points to some fault in the technique or impurity of the 
injection. More or less oedema of the site and its adjacent area 
may be noted, associated with slight or marked discoloration 
and pain of variable degree. The normal reaction following the 
injection is temporary and does not necessitate treatment or 
confinement of the patient, who can resume the duties of life 
fifteen hours after the operation. 

3. Infection. — The cause of infection cannot be said to be due 
to anything but surgical uncleanliness, as it is with any surgical 
undertaking, and can be overcome by the same means. 

The material injected should be thoroughly sterilized by boil- 
ing before using. Brceckaert 40 suggests combining an antisep- 
tic with the paraffine and has used guiaform, a combination of 
formic aldehyde and guiacol in a proportion of 5 to 10%) yet 
this is of little value when we consider how readily these hydro- 
carbons can be rendered sterile at high temperatures. 

4. Necrosis. — Death of tissue may follow an injection of paraf- 
fine when too much pressure has been applied, or when too 



12 HYDROCARBON PROTHESES 

much has been injected into the tissue, cutting off the blood 
supply, or when the injection has been made into the skin in- 
stead of beneath it. Again, constitutional disease, such as dia- 
betes or Bright's disease, may superinduce the breaking down 
of the tissue. 

Hyperinjection should and can be avoided by the use of the 
proper instrument with which the required amount is graduated 
to a nicety. At no time should an injection be crowded into a 
dense tissue or where the skin is closely adherent, nor carried 
so far as to create a blanching of the skin. By carefully inject- 
ing the mass this danger should be overcome. 

Dense or bound-down areas of skin should be loosened and 
freed, as has already been mentioned. 

If care be exercised and small amounts be injected, in prefer- 
ence to overcoming the defect in one sitting, pressure effects are 
entirely overcome. 

The circulation in the skin over the site of injection should 
be normal immediately after the operation has been performed, 
determined by observing the reaction in the color of the skin 
after delicate digital pressure. 

5. Sloughing. — That sloughing of the skin should be oc- 
casioned by the high temperature of the paraffine injected is a 
condition entirely inexcusable. Paraffine of high melting points 
5 8° to 65 C, or the so-called " Hart paraffine" employed by 
Wolff, 41 liquefying at from 5 y° to 6o° C, are to be used with, 
caution. The author doubts whether the temperature of the 
paraffine at the time of injection, even in the latter method, is 
ever beyond 54 C. even if the thermometer registers 6o° C. in 
the liquefying, hot water bath. 

By the time it has been drawn into the syringe, which has 



HYDROCARBON PROTHESES 13 

been heated by dipping into hot water, and the moment it is in- 
jected it has lost several degrees in heat. 

It would not be permissible to inject a molten mass of a tem- 
perature so high as to scar or burn the tissues, and the best re- 
sults of most operators have been obtained with such of the par- 
affine group that become liquified at a temperature of not over 
45 C. (112 F.). 

The claim of Eckstein, 42 that paraffines of low melting points 
are more likely to be absorbed, has not been substantiated in act- 
ual practice, since we now know that any and all of these injections 
irrespective of their melting points, are absorbed in time, giving 
place to connective tissue, and that rarely, if ever, is there a 
true and complete encapsulation or encystment of the mass thus 
introduced. Even the hard paraffines are split up in time into 
minute pearl-like particles which are displaced by the growth of 
tissue arising from the presence of the foreign substance. This 
is true even in those cases in which the author has introduced 
by surgical means solid paraffine plates in the cold state. 

6. Sloughing Due to Pressure. — When an injection is forced 
into a dense or firmly bound-down tissue, as into the body of a 
thickened cicatrix, or about the point of the nose or the sab- 
septum of the nose without first dissecting off the skin above 
the subcutaneous layers an acute anaemia is at once marked, 
followed by inflammation and gangrene. 

By injecting sterile water into the area thus loosened with the 
knife a good idea of the thoroughness of the dissection and the 
possibility of building up the part to be corrected, is obtained, 
yet in these cases the author has always found more or less 
difficulty in keeping the injected mass in place for the reason 
that the divided surfaces tend to unite at their peripheral bor- 



i 4 HYDROCARBON PROTHESES 

ders, crowding the mass upward or to one side or diffusing it in 
such a way that the result has been anything but satisfactory. 

To overcome this it is advisable to inject a smaller quantity 
than necessary to entirely correct the defect, to mould it out 
flat and to allow it to organize before more is introduced. 

7. Subinjection. — Insufficient injection leading to an under- 
correction of the defect is a far more desirable condition than 
hyperinjection and is easily corrected by a repetition of the 
treatment, even to a third sitting, until the desired result is ob- 
tained. Following this rule will give far better results, as has 
been said, than to be compelled to remove a part of the filling 
and some of the connective tissue which has resulted there- 
from. 

8. Hyperinjection. — The injection of too much vaseline or 
paraffine is one of the most common faults found with operators. 
In the first instance a tumefaction of the site results which with 
the production of the tissue which takes the place of part of the 
filling makes the result very unsatisfactory and requires one or 
more cutting operations to reduce it. A peculiar fact with these 
hyperplastic growths is that even though they may be reduced 
with the knife to a normal size they seem to redevelop again 
and again, giving both surgeon and patient great concern. 

This in the opinion of the author is due to the binding down 
of the marginal borders, which in the event of partial extirpa- 
tion, are not injured sufficiently to displace them and that they 
unite again in their former position. To overcome this it is 
found best to excise the entire filling much beyond the margins 
and to apply pressure over the area until perfect union has taken 
place. 

This is best accomplished with a disc of aluminium, bent to 



HYDROCARBON PROTHESES 15 

conform to the shape of the part operated, lined with sterilized 
lint and fixed over the site by strips of Z. O. plaster. 

While the hyperinjection of vaseline is not as objectionable 
as that of parafnne, because of the more ready accommodation 
and absorption of the mass, it nevertheless leads to diffusion of 
the material owing to its softer consistency and consequent 
greater facility in seeking fine avenues of escape, paraffine hav- 
ing the advantage of cooling upon itself en masse, leaving little 
to escape into undesirable channels after it has once been moulded 
and set. 

Vasserman 43 cites a case in which gangrene of the bridge of 
the nose resulted after an injection of 2\ c. c. of vaseline. 

However, when these faults occur they are errors of technique 
and should be avoided as has been mentioned heretofore. 

The removal of such hyperinjected masses by the aid of par- 
affine solvents, such as benzine, ether, chloroform or xycol applied 
to the skin above the filling has proved a failure, nor will heat 
used externally in the same manner remedy evil. 

What is left to the operator is to open the skin and, with a 
small, sharp spoon curette, remove the mass early, before it has 
become organized, or to excise the new connective tissue and 
the broken-down filling as mentioned. 

When, however, the tumefaction resulting from such hyperin- 
jection is not extensive, as is often found about the chin and at 
the root of the nose, the secondary deformity can be materially, 
if not entirely, remedied by electrolysis. A needle or brooch 
of certain hardness is to be employed, connected with the nega- 
tive pole of a continuous current apparatus. From twelve to 
twenty milliamperes are required. The process is similar to that 
used with the destruction of hair, naevi or moles on the face. 



16 HYDROCARBON PROTHESES 

The needle should puncture the entire tumor or penetrate its 
maximum diameter and be charged with the current for two or 
three minutes. Several of such punctures should be made at 
each sitting, the latter being repeated as often as is deemed nec- 
essary by the operator. The reaction which follows this pro- 
cedure is of little moment and these sittings can be undertaken 
every three or four days. 

While this method is liable to leave little punctuate scars at 
the sites where the needle is introduced, it is nevertheless more 
satisfactory than the linear scar made with the knife to the use 
of which the patient may on the other hand object, not to speak 
of the difficulty and unsatisfactory results usually obtained 
therewith. 

9. Air Embolism. — The fault of introducing air under the skin 
with the syringe at the time of injection can only be the result 
of flagrant negligence. Every physician should know enough 
to hold his syringe in an erect or vertical position and to expel 
the air above the solution in his syringe, as is done with any hy- 
perdermic injection. 

Air embolisms are also occasioned by a careless filling of the 
syringe with the hydrocarbon in a cold state, as the material is 
now generally used, and while the dangers of such emboli are 
very much exaggerated they should not be permitted, when by 
the pouring in of the liquefied material the syringe can be filled 
evenly. 

Practically there is no harm done by the injection of air un- 
der the skin, yet it elevates the skin at the site of the defect 
and hinders the surgeon in accomplishing the best results. 

These emboli cause a bulging up of the skin for the time being 
and may occasion more or less pain to the patient, which passes 






HYDROCARBON PROTHESES 17 

away in ten or twelve hours leaving the parts as injected except 
for such reactionary symptoms or oedema already referred to. 

10. Paraffine Embolism. — The creation of an embolism is in- 
variably due to an injection of the foreign substance directly 
into a blood vessel. This condition is one of the most objec- 
tionable, if not the most dangerous factor associated with the 
subcutaneous injection of any foreign matter, be it a liquid sub- 
stance, as, for instance, an oil ; many cases have been placed on 
record where they have been observed after the introduction of 
even paraffine of high melting points, when introduced under 
the skin in hot liquid state. Consequently the use of vaseline 
liquefied by the aid of heat is especially liable to give rise to such 
condition. 

Pfannenstiel 44 cites a case wherein he injected paraffine in 
which the patient was at once attacked with violent coughing 
and for three days exhibited symptoms of grave nature, such as 
pain in side, intense dyspnoea, acceleration of the pulse, hyper- 
thermia, cyanosis of the face, hemoptysis, violent cephalalgia and 
vomiting — all indications of pulmonary and cerebral embolism. 
The injection in this case was one of 30 c. c. of paraffine, with 
a melting point of 45° C. The symptoms as mentioned con- 
tinued for about one week, gradually subsiding and followed by 
recovery. 

Kapsammer 45 has also noticed such symptoms. Leiser 46 
after injecting vaseline to correct a saddle nose noted an im- 
mediate collapse of the patient which was obviated only by the 
hypodermic use of ether and the resort to artificial respiration. 
When the patient returned to consciousness, he was found to 
be entirely blind in the right eye, the eye before the operation 
having been known to show only a pronounced astigmatism. 



18 HYDROCARBON PROTHESES 

Kofman 47 cites the loss of a patient from the injection of 
10 C.C. of paraffine for vaginal prolapsis. Moskowicz 48 ob- 
served two cases of pulmonary embolism treated in the same 
manner stating that an alarming dyspnoea continued for several 
hours. 

Especially have cases in which the injections of paraffine were 
made sub-mucously for the correction of atrophic coryza shown 
embolic tendencies. This is especially true when paraffines of 
high melting points have been employed, as in the case of 
Pfannenstiel in which instance the condition of the mass per- 
mitted of freer absorption or the high temperature caused a 
coagulation of the blood in the veins, leading to thrombosis and 
embolism, and when the amount of such an injection is so large 
as to prevent cooling and hardening in the normal space of time 
added to the quantity and associated at the same time with con- 
sequent pressure, predisposing to absorption or dissemination, 
especially if the injection be made into parenchymatous instead 
of the subcutaneous tissue. 

Comstock 49 in his experience on animals, states that, "in all 
cases in which paraffine was used at 102 F. the animals died 
within two weeks' time, hence the specimens at that tempera- 
ture are limited (death being by thrombosis). In all other 
cases with the higher melting point 1 io°F. no unpleasant results 
were experienced." 

Hurd and H olden 50 have observed a patient who had previ- 
ously undergone two injections of paraffine for the correction of 
a depression in the upper part of the nose. A third injection 
was advised and made under the same conditions as the first, 
except that no cocaine anesthesia was employed, the paraffine 
being at the same temperature as before. 



HYDROCARBON PROTHESES 19 

The moment the injection was made complete blindness in 
the right eye resulted, while a small ecchymotic spot appeared 
at the site of the needle insertion in the skin. Half an hour 
later an examination of the eye showed the right pupil dilated 
and inactive light stimulus, the patient being unable to distin- 
guish light from darkness. Opthalmoscopically the lower branch 
of the central retinal artery and its subdivisions were found to 
empty and in a state of collapse, evidenced by their pale ap- 
pearance. The upper branch of the same vessel was found to 
be poorly filled. 

The authors endeavored to remove the embolism to a collat- 
eral branch of the artery by the use of amyl nitrate, digitalis 
and pressure on the globe of the eye, with no effect. Some 
hours later oedema of the retina appeared, followed by perma- 
nent loss of sight. The same authors have observed several 
cases of pulmonary embolism result from the injection of par- 
affine. 

It is also a fact that injections of the nature being considered 
while not causing immediate embolism may do so as a result of 
phlebitis caused by a direct injection into the vein or over or 
upon it in such a way as to cause irritation. 

Mintz 51 reports a third case of amaurosis following a paraf- 
fine injection. The latter was made to correct a saddle deform- 
ity caused by syphilis. Three minutes after the injection the 
patient complained of pain in the left eye which was followed by 
total blindness, vomiting and a pulse of forty-eight. Several 
days later there appeared symptoms of venous congestion in the 
orbit, paralysis of the ocular muscles, corneal cloudiness and ex- 
aphthalmos a small grangrenous spot appeared at the site of the 
injection. 



20 HYDROCARBON PROTHESES 

Brcecksert 52 observed a case of facial phlebitis, followed by 
pulmonary infarction. Brindel 53 cites a case in which he ob- 
served a hard line of considerable extent and painful to the 
touch, extending from the inner angle of the eye to the angle 
of the eye, where it deviated towards the root of the nose and 
terminated at the origin of the eyebrow. 

De Cazeneuve 54 made an injection and on the following day 
noted that the right cheek had increased considerably in size 
with an elevation of temperature in the part. Two days after 
under the right eye and to the right of the nose the whole cheek 
was red, hot and much distended, giving the skin a glazed ap- 
pearance. Palpation was extremely painful. A hard line could 
be made out extending from the inner angle of the eye outward 
and downward under the lower eyelid and terminating in the 
center of the cedematous cheek. The phlebitis in this case re- 
sulted without the development of an embolism. 

After a careful study of the causes of such embolisms we 
come to the conclusion. 

i. That the injected mass should not be heated above a cer- 
tain melting point. 

2. That hyperinjection should at all times be avoided, partic- 
larly with paraffines of high melting points. 

3. That the injection should be made subcutaneously not into 
parenchymatous tissues, and 

4. That a puncture of a vein or the introduction of the in- 
jected mass into a vein should be avoided. 

In the consideration of the first two causes the author advocates 
using injections of low melting points only at all times, in fact 
from his experience with over two thousand subcutaneous in- 
jections he relies entirely upon such paraffines or hydrocarbon 



HYDROCARBON PROTHESES 21 

mixtures as are semisolid at yo° F. appearing as a white cylin- 
drical thread from the needle of the syringe as pressure is ap- 
plied. 

With such a preparation and a careful introduction of the 
needle as described later and with the injection of an amount 
much less than that needed to correct the deformity and proper 
digital compression on the blood vessels and about the site of 
the injection embolism is practically impossible. 

The avoidance in the third instance is self-evident and it is 
to the fourth fault and cause that we must pay particular atten- 
tion. 

Stein 55 says that all that is necessary to avoid puncturing a 
vein is to first introduce the needle alone under the skin and to 
attach the syringe only when it is found no flow of blood re- 
sults from the puncture thus made. 

Freeman 56 and the author add to this by advocating the use 
of a somewhat blunt pointed needle instead of the extremely 
sharply pointed knife-edged needles usually furnished with 
syringes intended for this purpose. 

11. Primary Diffusion or Extension of Paraffine. — The spread- 
ing of parafnne into normal tissues about the site to be corrected 
by prothetic injection is a fault due principally to a careless use 
of the syringe. The employments of an improper syringe in 
in which the amount to be injected cannot be graduated or con- 
trolled will be considered later — the result with such being hy- 
perinjection. In this event when the anterior line of the nose 
is to be restored, the mass is liable to find its way into the loose 
areolar tissue of the infraorbital region ; in correcting a nasola- 
bial furrow the mass is pushed upward or is forced into the tissue 
of the cheek above'it aggravating the trouble ; in obliterating a 



22 HYDROCARBON PROTHESES 

frown it travels upward toward the margin of the scalp giving a 
median prominence to the forehead that is found to be very dif- 
ficult to correct ; in injections about the mouth the mass moves 
down upon the chin or accumulates at the angle of the jaw ; in 
correcting the creases beneath the chin it seeks the sides of the 
neck, even travelling to the superior border of the clavicle at its 
sternal third. Many other forms of such diffusions can be 
mentioned directly due to primary diffusion the result of hyper- 
injection. 

Enough has been said of the danger of hyperinjection, yet 
even with a proper amount of the injected mass this distention 
may by observed. To avoid this the operator, or his assistant, 
should compress the margins of the site of the injection with 
his fingers firmly applied, as for instance in the injection of the 
root of the nose pressure should be made at both inner canthi 
and over the tissue just above the root of the nose and beneath 
the finger tips. 

Downie 57 advocates the use of celloidin in the correction of a 
saddle nose as follows : He paints a band of celloidin or colo- 
dion down each side of the nose limited by the line of junction 
with the cheeks and another band across the root of the nose. 
These painted on bands he allows to dry and contract for fif- 
teen minutes before undertaking the injection. 

The contraction of these bands, prevents to a certain extent 
the spreading or extension of the liquid paraffine into the celu- 
lar tissue about the eyes, yet experienced digital pressure is at 
all times to be preferred. 

If a liquid paraffine or hydrocarbon mixture or vaseline is 
used, the immediate use of ice cloths applied to the part as dig- 
ital pressure is removed, is advisable to aid in the rapid har- 



HYDROCARBON PROTHESES 23 

dening or setting of the injected mass before the tension of the 
tissues over and about it, might influence it. With semisolid 
injection this is not necessary, except in the subsequent treat- 
ment as will be considered later because the mass, unless of too 
soft a consistency, as for instance vaseline will practically re- 
main as injected and moulded. 

Vaseline when injected into tissue where there is tension would 
naturally be forced out of position and shape and should not be 
used except in combination with a paraffine of a melting power 
high enough to give the proper consistency to the former. 

12. Interference with Muscular Action of the Wings of the Nose. 
— That nasal respiration may be encroached upon as a result of 
injecting paraffine about the nose has been observed by Alter. 58 
He points out that during nasal inspiration there is a tendency 
for the alae to contract upon themselves or to move inward de- 
creasing the lumen of the orifice and that in the normal state 
this movement is counteracted by the action of dilator muscles 
of the alae, that is the dilator naris anterioris, the pyramidelis 
nasi and the levator labii superioris alaeque nasi and that this 
muscular action is interfered with owing to the pressure of the 
paraffine upon these delicate structures and resulting in more or 
less permanent collapse or indrawing of the alae during inspira- 
tion. He observed considerable interference with inspiration in 
a case cited in which an injection of paraffine had been made. 

To avoid undue pressure upon the structures referred to it is 
advised to have an assistant place a thumb into each nostril and 
the index fingers without and above the alae in such way that 
the tips of the fingers may be enabled to exert the necessary 
pressure over the injected mass into these structures, and to 
maintain this pressure until the mass has been properly moulded 



24 HYDROCARBON PROTHESES 

and set. Connell 59 advises inserting the little fingers into the 
nostril to prevent an encroachment on the lumen of the nasal 
canal. 

The above applies particularly to those cases where injections 
are made into the anterior lower or lateral third of the nose, as 
for instance in overcoming slight depressions in the anterior 
line, immediately above the lobule or in a low unilateral deviation 
of the nose. 

13. Escape of Paraffine after Withdrawal of Needle. — When 
the injected mass employed is of a semisolid consistency as 
heretofore advised, it is hardly possible for the mass to be forced 
out through the opening of the skin made by the introduction 
and withdrawal of the needle, unless there be an unwarrantable 
immobility of the skin above the site to be injected. The latter 
should be corrected before injection. 

The mass after having been moulded in the shape desired 
may be further hardened and set by the application of ice cloths 
or spraying with ether before the needle is withdrawn from the 
skin, yet this is hardly necessary and the author advises against 
the practice for the reason that pressure of the needle prevents 
proper and free moulding of the mass and renders the tissue 
liable to further injury by scraping its point to and fro subcu- 
taneously adding to the extent of the wound and the dangers 
of infection and repair. 

The skin immediately around the needle hole, after with- 
drawal of the needle, may be gently smoothed out with the dull 
rounded metal handle end of the bistoury to free the inter- 
dermal canal of any foreign matter. 

The skin about the needle hole is then gently washed with a 
$0% solution of hydrogen peroxide, dried with a sterile cotton 



HYDROCARBON PROTHESES 25 

sponge and the opening sealed with a drop of collodion. Sub- 
sequent treatment of the parts will be considered later. 

14. Solidification of Paraffine in Needle. — This occurs only 
when paraffines of high melting points are employed in liquid 
form in the syringe, and is due to the rapid cooling of the par- 
affine in the small metallic canulae, or needle, wherein it sets 
more readily since the volume contained therein is very small, 
often not more than two or three drops. 

This cooling establishes a plug-like formation in the distal end 
of the needle which prevents a proper use of the syringe, often 
breakage, and when suddenly liberated by an extra pressure on 
the piston rod causes a rapid discharge of the contents of the 
syringe to an extent not desired with the result of hyperinjection. 

This fault was one of the most annoying in the early days of 
such injections when syringes of ordinary pattern, such as the 
Pravaz, or those built like the ordinary hypodermic were used. 
It was not unusual to have the paraffine cool in the needle so 
quickly between the latter in the flame of an alcohol lamp, that 
the syringe became unmanageable and broke in the hands of 
the operator. Since that time new and more useful syringes 
have been introduced by various operators which overcome this 
difficulty, yet with them, too, come the employment of semi- 
solid paraffines or mixtures thereof. Yet as some authors in- 
sist upon using paraffines of high melting points it may be well 
to rehearse their methods of overcoming this annoying intra- 
needle solidification. 

Eckstein 60 surrounds the syringe and needle shaft, except the 
tip of the needle, with a rubber tubing as shown in Fig. I, 
to act as an insulator and thus, for a time at least, keep the 
preparation liquid. Before filling the syringe he heats it by sev- 



26 



HYDROCARBON PROTHESES 



eral immersions in and internal washings of hot sterile water. 
To prevent the paraffine from setting in the exposed tip of the 
needle he draws into the filled syringe a few drops of hot water 
which are injected into the tissues, causing no objection to the 
method. 

Paget 61 and Harmon Smith 62 warm the needle in hot steril- 
ized or even boiling water. Previous to this Smith cools the 




Fig. I. Eckstein's Insulating Sleeve. 



contents of the syringe drawn into it at a temperature of 120 F. 
by immersing the latter in a bath of sterilized water at a tem- 
perature of 8o° F. 

From the above it will be noted that Smith advocates using 
the injections in semisolid state being ejected in a thin, cylin- 
drical thread. A syringe of special construction as referred to 
laser is of course required for such work. 

Quinlan 63 has invented a so-called paraffine heater as shown 
in Fig. II, in which the paraffine is kept in solution by the 
syringe being surrounded by a continuous flow of hot water. A 
plain and very objectionable syringe is shown in the illustration 
and while the preparation in the syringe is thus kept in a liquid 
state the solidification in the needle is not overcome. 

Downie 64 winds fine platinum wire about the needle through 



HYDROCARBON PROTHESES 



27 



which he passes the current from a storage battery to keep the 
needle hot yet such an arrangement is obviously difficult of 
manipulation and when paraffines of high melting points are em- 
ployed it is quite likely that a plug is 
formed in the exposed point of the 
needle. 

Karewski 65 has introduced a syringe 
having a jacket through which hot 
water is allowed to circulate, while sim- 
ilar instruments have been originated 
by Pflugh 66 and DeCazeneuve. 67 None 
of these overcome the difficulty in 
question. 

Viollet 68 went even further by invent- 
ing a syringe surrounded with a coil of 
resistance wire, heated by an electrical 
current, and Delangre, 69 Ewald 70 and 
Moszkowicz 71 use special thermophorm 
sleeves over the syringe proper, all how- 
ever offering the same objection in the 
exposure of a part of the needle in 
which temperature of the liquid must 
necessarily be lowered, or be low enough 
to cause plugging, the very fault for 
which all these modifications have in- 
cidentally been urged, as the greater 
amount of paraffine in the syringe itself is as a rule large enough 
to retain sufficient heat to permit of its ejection, if the in- 
jection is made as expeditiously as possible. 

The objection of the setting of the paraffine in the barrel of 




Fig. 



II. Quinlan's Paraf- 
fine Heater. 



28 HYDROCARBON PROTHESES 

the syringe has never hampered any operator, the difficulty in 
these instances having been entirely due to the obstruction 
offered its ejection by the thread-like plug obstructing the 
metal-canula before it ; the barrel being glass retains its tempera- 
ture more readily than the thin metal needle, hence the diffi- 
culty. 

That all prothetic preparation of the nature in hand should 
be placed in the barrel of the instrument in liquid form is es- 
sential, in that the syringe is thus filled to its required height 
evenly, and devoid of air spaces, yet in the light of the best and 
most successful results the mass should be allowed to cool and 
be ejected in semisolid state from a specially constructed in- 
strument to be described later. 

With such method it is impossible to have an occlusion of 
the needle at any time and the objection of sudden outbursts of 
unknown and undesirable quantities of the mass is entirely 
overcome. 

15. Absorption or Disintegration of the Paraffine. — The ques- 
tion of the ultimate disposition of paraffine, injected subcutane- 
ously for any purpose, has been an extensive one in which many 
operators have taken part. 

Gersuny 72 at first claimed an encapsulation for the injected 
mass of vaseline, which he states was not taken up by the lym- 
phatics but remained in situ as an inert, non-irritating body. 
Shortly after it was shown that the encapsulated mass soon be- 
came ramified by newly formed, fine bands of connective tis- 
sue which developed more and more in the part until the entire 
mass had become displaced by this tissue with an eventual con- 
sistency of cartilage. 

Eckstein 73 claims that at first a capsule of new connective 



HYDROCARBON PROTHESES 29 

tissue encloses the injected mass (Hart paraffine) a few days 
after the latter is injected, which can be easily stripped away 
from the encapsulated matter several weeks or months after, 
showing a smooth inner wall, the encysting capsule showing a 
decided lack of blood vessels, proving histologically its relation 
to the structure of cicatricial formation. 

In this Eckstein is undoubtedly mistaken. He objects to the 
ultimate replacement with connective tissue for the vaseline 
process of Gersuny, when in reality we have begun to realize 
that such result will follow any hydrocarbon subcutaneous in- 
jection unless the latter be made in small quantity into parts of 
the body which are in constant motion. 

The latter is shown with injections of paraffine made into or 
about the nasolabial fold. The tumor is so small as to be 
hardly felt by the palpating finger, but soon takes on larger 
proportions evidencing an encapsulation of some extent or less 
independent of the encysted mass. That this is true can be 
ascertained by incising these little hard tumors when the con- 
tents can be readily pressed out or evacuated, the mass appear- 
ing practically as injected months before. 

The same result is show by Harmon Smith 74 who made an 
injection of paraffine (no°F.) into the peritoneal cavity of a 
rabbit which was killed 22 days later. On examination no sign 
of inflammation of the peritoneum was found — a fact that seems 
to prove the nontoxic effect of paraffine — nor were there evi- 
dences of the formation of adhesions. The mass had become 
rounded, had travelled about the abdominal cavity and was found 
lodged between the liver and the diaphragm. 

Comstock 75 with his experiences of injections of paraffines at 
high melting points, found that the harder paraffines do not be- 



So 



HYDROCARBON PROTHESES 



come encysted but become a part of the new tissue, which be- 
lief is corroborated by Downie 76 who introduced paraffine into 
a carcinomatous breast. Upon subsequent amputation and mi- 
croscopic examination, there was shown an intimate connection 
between the ramified site of the injection and the surrounding 
tissue. The same results have been noted by JuckufL 77 

Smith 78 found, that in trying to remove all injected mass of 
paraffine several months after introduction, the greater part of 
the mass had become so thoroughly embedded in the meshes 
of the newly formed connective tissue that it was practically im- 
possible to remove it without including a considerable portion 
of the connective tissue as well. 

Stein 79 claims also that the paraffine is absorbed, little by 
little, as it is replaced by the new connective tissue, no matter 
what the melting point of the introduced paraffine might have 
been. The mass grows smaller to a degree according to the 
amount injected ; finally at the end of a month or more, the en- 
tire mass is replaced by a tissue perceptibly analogous to carti- 
lage. 

Freeman, 80 like Eckstein, claims that encystment of the par- 
affine occurs soon after the injection, much like that following a 
bullet or other foreign body in the tissues, but unlike the lat- 
ter author, that a limited amount of the connective tissue also 
penetrates the mass which is speedily converted into a solid 
cartilage-like body. 

Wendel 81 believes entirely in the encystment theory, while 
Hertel, 82 in specimens removed twelve to fifteen months after 
injection of paraffine with a melting point of ioo° F, found a 
wall of round cells under various states of inflammation sur- 
rounding the masses with fibers of connective tissue traversing 



HYDROCARBON PROTHESES 31 

the latter. In the various histological findings he argues that 
the greater the tissue surface exposed to the injected foreign 
body the greater the irritation and the larger the smooth par- 
affine mass the less the reaction, in other words, small masses 
of the injected mass cause a higher rate of tissue formation 
while the larger masses have a tendency to encystment merely. 
He also believes that the harder paraffines require a greater 
length of time to become absorbed, and that during such time 
of resorption new connective tissue growth is established con- 
tinuing to the time of its complete disappearance. 

Comstock 83 after thorough and extensive investigation with 
the injection of paraffines of various melting points made at 
varying times after the injection of such procedures concludes 
definitely that, " In paraffine we have a substance that will fill 
in spaces of lost tissue, and not remain entirely a capsulated 
foreign body, but become a bridgework and, in fact, a part of 
the new tissue." 

Wenzel 84 after an unsuccessful attempt to overcome a lap- 
arocele by the injection of paraffine, a year later performed a 
radical operation of the parts. The excised tissue at the site of 
the injection showed deposits of the broken up mass of paraf- 
fine each being enveloped by a capsule of connective tissue 
without any signs of ramifying bands and hence decided against 
the belief of the resultant tissue formation. 

Eschweiler, 85 the latest authority on the above question, after 
examining microscopically a portion of paraffine injected tissue 
that had been carried " in situ " on the bridge of the nose for 
about one year concurs absolutely with the connective tissue 
replacement belief. 

From the foregoing it may be definitely accepted that while 



32 HYDROCARBON PROTHESES 

there may be an encapsulation or encystment of the injected 
mass, be what it may so long as it belongs to the paraffine group, 
there is always a ramification of the mass by the formation of 
strands of new connective tissue which eventually in a month 
or more according to the amount of the mass, develops to a size 
corresponding to the latter or even beyond the size of the latter 
as will be mentioned later, and that in all cases the paraffine is 
ultimately and almost, if not completely, crowded out of the 
area occupied by the injection and that its disappearance is ac- 
countable to absorption. 

This absorption, following such an injection, is productive of 
no harm to the human economy and the new tissue caused to 
be formed by such injection truly enhances the cosmetic and 
surgical value of the method in as much as an encapsulated 
mass of paraffine is liable to displacement, spreading and ir- 
regularities should it be subjected at any time to external 
violence. 

Such violence, again, would lead to the irritation and inflam- 
mation of such cyst wall causing an undue crowding upon the 
parts injected and possible gangrene of that part of the wall 
upon which such pressure was brought to bear, leading to un- 
sightly attachment and ultimate contraction of the skin where 
bound down by the inflammation, or even evacuation by the ab- 
sorption of gangrenous material and resultant abscess. 

That this absorption or disintegration of paraffine is of no con- 
sequence may be proven by all the early cases in which such 
injections were used. Gersuny's first case having been done 
May, 1899, shows no diminution of the prothetic site at the 
end of two years. The same may be said of the hundreds of 
cases done by other operators. 



HYDROCARBON PROTHESES 33 

The greater question in the mind of the author is what will 
be the ultimate behavior of this new connective tissue. 

That the development of this new connective tissue is grad- 
ual has been mentioned, some authors claiming a complete re- 
placement of the mass at the end of a month, others from two 
or three months. Morton 86 says that four months time is re- 
quired before the mass is, more or less, completely removed and 
replaced by organized tissue. The author believes, however, 
that the length of time necessary for this replacement not only 
varies, proportionately with the amount of paraffine injected but 
that it differs in each case, and markedly with some patients in 
which the growth or developments of the new tissue did not 
cease for months and even a year after such injection. This 
corresponds truly to a hyperplasia and will be considered later. 

Time alone will show the ultimate behavior of this new tissue, 
and while it is reasonable to argue that this newly organized 
tissue could cause no untoward results, it must be determined 
whether this tissue will not undergo atrophy and contract, or 
become susceptible to other changes in time. It is a new tissue 
practically, and as yet we know nothing of its idiosyncrasies, 
although its histological nature is determined. 

We do not know that irritations, such as surgical interference, 
will cause it to take on new growth, as evidenced by the at- 
tempts of extirpation of unaccountable overcorrections obtained 
with injections made early in the time of the employment of the 
Gersuny method, in which the parts practically grew back to 
their former size or became even larger. This may be ac- 
counted for by the fact that most, if not all, of the connective 
tissue was not removed or points to an active nucleus or several 
such centers which were not destroyed. 



34 HYDROCARBON PROTHESES 

That the growth is not limited by the size of the mass in- 
jected is the author's belief, in other words, the replacement of 
the new tissue is not proportionate to the injection, but that 
other forces, such as adjacent tissue pressure and presence and 
outer influences, as for instance the daily massage of the parts 
with the hands have much to do with the final amount of tissue 
caused to be developed by the initial stimulus of the injection. 
Nothing further or definite however has been written on this 
supposition. 

1 6. The Difficulty of Procuring Paraffine with the Proper Melt- 
ing Point. 

This should not prove an objection to the method, since 
operators can procure pure and sterilized paraffines of the vari- 
ous melting points from any reliable chemical house. 

What the operator should determine first of all is the kind of 
paraffine he intends to use for subcutaneous injection. 

The selection of paraffine of a certain melting point should 
be influenced by what he has read on the subject as given by 
authorities of wide experience. 

A few cases do not suffice from which to draw conclusions ; 
it is only from a great number of similar operations that a 
definite form or preparation of paraffine can be decided on. 

From the following authorities is shown a variance in the 
melting points of the preparations used, but by a glance it may 
be noted that the first division of men, from numbers I to 
10 inclusive, use paraffines of melting points very near to each 
other ; the latter group, from 1 1 to 13 inclusive, employ those 
of the higher melting points. 

The former group may therefore be said to utilize the par- 
affines of lower melting points. 



HYDROCARBON PROTHESES 35 

GROUP I 

1. Gersuny 87 36-40 C. 97-104 F. 

2. Moskowicz 88 36-40 C. 97-104 F. 

3. Parker 89 102 F. 

4. Freeman 90 40°C. 104 F. 

5. A. E. Comstock 91 107 F. 

6. Walker Downie 92 104-108 F. 

7. A.W.Morton 93 109 F. 

8. Harmon Smith 94 no°F. 

9. Stephen Paget 95 io8-ii5°F. 

10. Pfannenstiel 96 H5°F. 

GROUP II 

11. Broecksert 97 56 C. 133 F. 

12. Eckstein 98 5 6-5 8° C. 133-136 F. 

13. Karewski" 57-6o° C. 134-140 F. 

From a glance of the first group the variance of the tempera- 
ture of melting points is not a great one, practically lying be- 
tween 102 and 1 1 5 F. approximately. When we consider the 
actual difference in the employing practicability and the effect 
upon the tissue there is practically little, if any, difference. 
The only difference between these authorities is that some em- 
ploy their preparation in liquified form, through the application 
of heat, while the others employ it in the cold or semisolid form. 
The choice of such method, from what has already been said, 
should unreservedly be the employment of a paraffine in the 
cold or semisolid form at a mean temperature of about 1 io° F. 

This choice would fall upon any one of the parafrlnes used by 
the authorities given in Group I. 



36 HYDROCARBON PROTHESES 

The objections to the " Hart paraffines " of melting points 
given in Group II have been sufficiently shown in preceding 
paragraphs, although a few pointed objections from the various 
surgeons may not be out of place here to offset the claims and 
advocacies of those employing the preparation in liquid form at 
higher temperatures than i io° F. 

Paget 10 ° says, " I am absolutely sure now that Eckstein's 
paraffine is without any real advantage. It is very difficult 
to handle ; it sets very rapidly ; it causes a great deal of swelling 
and some inflammation and may even produce some discolora- 
tion of the skin, and it yields no better results than does Pfan- 
nenstiel's paraffine, which melts at I io° F." 

Again he says, " the best paraffine is that which has a melt- 
ing point somewhere between 108 and H5°F. When the par- 
affine has to stand heavy and immediate pressure, the higher 
melting point is preferable." 

He had up to the date of the latter extract operated upon 
forty-three cases of deformed noses and " in no case was there 
embolism, sloughing of the skin or wandering of paraffine." 

Paget, however, employs the paraffine in liquified form, and 
allows cold water to trickle over the nose while the injection is 
moulded into form. Of this later. 

Comstock 101 says, " Paraffine must be used where it will be at 
all time above the body temperature " and further that, "in select- 
ing the melting temperature for surgical uses, it should be that 
from 1 06 to 107 F. the best for use in subcutaneous injections, 
for the reason that it gives a substance firm enough to hold 
very well its form, especially when confined by the surrounding 
tissue, and at the same time with a melting point out of the reach 
of the system at all times." 



HYDROCARBON PROTHESES 37 

From this we are given to understand that he uses his prep- 
aration in cold form entirely when injecting, but of the melting 
point mentioned. 

The author can see no advantage in using any paraffines 
of low temperature melting points in liquid form. Here is 
the very factor of causing embolism reintroduced. Surely a 
liquid of any kind injected into a blood vessel will give cause 
for trouble, even if the temperature of the setting of such a par- 
affine be high or low. The employment of the paraffines of a 
melting point above 120 F. in cold form is difficult, if not im- 
possible, even with the latest pattern of screw syringe which is 
quite true, but there is no need of using such paraffine nor any 
liquified paraffine since any such preparation of about the melting 
point of 1 io° F. will serve every purpose overcoming all the ob- 
jections of the advocates of those using any other. 

If a vessel be injected and filled with any paraffine preparation 
there is danger of phlebitis and thrombosis, the only possible 
way to overcome it is not to puncture the vessel. 

While a preparation injected cold can be more easily governed 
from without by digital pressure or guidance, what can be said 
for a hot seething preparation introduced under great pressure ? 

Furthermore, when paraffine is injected in liquid form, es- 
pecially when so rendered by a temperature necessarily even 
higher than the actual melting point, there is danger of searing 
the entire site intended for injection — a condition inducive to 
no good and a burning of the skin where the necessary super- 
heated needle enters it, causing a punctate scar, more or less 
painful during the time required to heal the wound. 

With the later knowledge that small amounts should be in- 
jected and that such injections should be repeated, it being 



38 HYDROCARBON PROTHESES 

known that such method 'facilitates the production of new con- 
nective tissue may we not draw the conclusion that the result 
obtained by the injection depends not upon the injection per se, 
but the resultant of that injection, namely tissue production and 
that this tissue production is the outcome of a stimulus in the 
form of that injection. 

There has not appeared an authority who has claimed other- 
wise for injections of paraffine hot or cold, while it is true that 
the use of liquified paraffines at high temperatures have caused 
all sorts of untoward results while those of lower melting points, 
in similar form have not escaped objections. 

The author has used the cold injection method in over 300 
nose cases without a single case of sloughing, embolism or death, 
and in no case was there secondary diffusion or hyperinjection. 
The only fault has been the desire on the part of the patient 
to be finished too quickly which usually leads to a result not as 
satisfactory as when the injections are made sufficiently far 
enough apart to allow the formation of organized tissue at the 
site of injection. 

Gersuny's preparation of paraffine, particularly useful for the 
cold injection method, is made as follows : A certain amount of 
cold paraffine melting at about 1 20 F. and white cosmolin or 
vaseline, melting at about ioo° F. are mixed by being heated to 
liquification. The bulb of a clinical thermometer is then coated 
with the cooled mixture of paraffine which is then placed into a 
hot water bath the temperature of which is gradually raised un- 
til the paraffine melts and floats upon the surface of the water. 
The water is then allowed to cool and its temperature noted 
just as the oil-like liquid paraffine begins to look opaque, which 
marks the melting temperature point of the mixture. 



HYDROCARBON PROTHESES 39 

Should this be found to be too high more vaseline is added, 
or vice* versa until the desired quantity of both is known. 

This method of preparation is however a tedious and awkward 
one and can be readily improved upon by mixing certain known 
quantities of the one with the other after the first experiment. 

The author recommends the following formula for the prepa- 
ration of a mixed paraffine which he has found serviceable and 
satisfactory for use with cold process injections and employed 
by him for the last four years. 

Paraffine (plate, sterile) 5 ii 
Vaseline alba (sterile) § ii 



R 



The two are placed into a porcelain receptacle and melted in 
a hot water bath to the boiling point, then thoroughly mixed by 
stirring with a glass rod and poured into test tubes of appropriate 
size and allowed to cool. Each tube is sealed properly with a 
close fitting rubber cork which may be coated with a liquid 
paraffine without, including the neck of the tube and put away 
for later use. 

Since 1905 the author has used an electrothermic heating 
device in which the paraffine mixture is prepared. The apparatus 
is made up of a metal pot set into the resistance coil and is 
shown in Fig. III. 

This instrument overcomes the complications of the water 
bath and the burning or browning of the paraffine mixture so 
commonly found with ordinary methods. The temperature of 
the resistance coil within the heating chamber being controlled 
by a small rheostat at will. 

Before using, the contents of each test tube thus prepared are 
reheated to sterilization and poured into the barrel of the syringe 



40 



HYDROCARBON PROTHESES 



to two.th.rds of its length, the piston introduced and screwed 
down mto ition . the syringe bdng ^ screwed 

«s contents have been cooled, or the entire instrument i Z 
mersedin stenhzed water at about ^F. until the parage 

zt 5 sr r becomes unifo ™ in — «r. « take : 




Fig. III. Kolle's Electric Paraffine Heater. 

f rom P f T SCre ? g d ° Wn the PiSt ° n the maSS WiI1 be fou "d to issue 
u^nts C " a *' CyIindrkal thread "* iS ™<» « 
Harmon Smith -has had such a paraffine prepared which 
has a meltrng pomt of no" F. This can be purchased in the 
market m stenle sealed tubes ready for use. The contents ox 



HYDROCARBON PROTHESES 41 

these tubes should however be resterilized at the time of em- 
ployment. 

The same author prepares this paraffine of no° F. melting 
point by mixing sufficient petroleum jelly (evidently white 
vaseline) with the commercial paraffine melting at about 1 20 F. 
to bring the melting point down to 1 io° F. He claims that 
making such a mixture is a difficult matter, since a plate of par- 
affine will have various melting points, one corner melting at 
120 and the opposite as high as 140 F. He advises having 
the mixture accurately prepared in large quantities and dispens- 
ing it in test tubes of one-half ounce capacity as now found on 
the market. The mixture is poured in hot liquid form into 
these test tubes which are then sealed with wax and placed on 
a sand bath whose temperature is raised to 300 F. to insure 
sterilization. 

The latter author has devised a neat paraffine heater shown 
in Fig. IV. 

Of this he says, " To insure still further the sterilization of 
the paraffine, I have devised a tin (nickle plated) receptacle 
supported on an attached tripod, which raises the bottom an inch 
from any planejsurface on which placed and is closed with a de- 
tachable lid. This arrangement prevents the paraffine from 
burning or browning. Into this I pour the paraffine from the 
test tube, after melting, and place this receptacle into a steril- 
izer, or any ordinary boiler — surround it almost entirely with 
water and then boil. After I have boiled it for a few minutes, I 
remove the receptacle and permit it to cool until the paraffine 
therein is about 120 F. I then draw it up into the syringe 
which has been sterilized in the same boiler with the paraffine. 
When sufficient is withdrawn, I evacuate the air bubbles from 



42 



HYDROCARBON PROTHESES 



the syringe by pressing the piston upward and run my set 
screw into place. Some two or three minutes are now allowed 
for the paraffine to assume equal consistency throughout and to 
cool down to a semisolid state. When the paraffine reaches 
this consistency it may be kept many hours ready for use, at 
the temperature of the room, if only the precaution to warm 
the needle is taken each time before attempting the injection." 




Fig. IV. Smith's Paraffine Heater. 

17. Hypersensitiveness of the Skin. — A permanent hypersen- 
sitiveness of the skin over the site of a subcutaneous paraffine 
injection has never been definitely shown. While it is true 
there is some pain and feeling of stress and fullness over and 
about such area, immediately after the operation, this has sub- 
sided in about twenty-four hours in the average case, except in 
those where a very hot liquid paraffine and of large amount has 
been injected, when several days are required to overcome these 
symptoms. 



HYDROCARBON PROTHESES 43 

Smith 103 claims a numbness over the site of the injected 
area which soon passes away, but this is perhaps more a feel- 
ing of fullness rather than one of anesthesia. 

The author has observed, however, in several cases a period 
of extreme discomfort, fullness and cephalagia in cases of subcu- 
taneous injections about the root of the nose. Peculiarly these 
attacks appear only after the filling has become organized that is 
after the connective tissue has displaced the paraffine. The 
secondary tumor in such cases appears to be slightly larger 
superiorly than the original size at the time of injection. 

The irregularity of these attacks, with oedema of the forehead 
and slight puffing of the upper eyelids, points to a disturbance 
of the circulation and is undoubtedly due to pressure on the an- 
gular vessels, and the venous arch across the root of the nose. 
The symptoms usually appear in the early morning and moder- 
ate towards night, reappearing again the next morning or not 
again until the next attack which may be expected at any 
time. 

This condition of affairs is an unfortunate one, since we can- 
not look to the avoidance of the trouble nor foresee it at the time 
of operation. In one case the symptoms did not develop un- 
til nearly two years after the injection was made and became 
so troublesome that the only relief had was by opening the skin 
of the nose laterally and excising as much as seemed necessary 
of the newly formed connective tissue with a fine pair of curved 
scissors. None of the injected matter was discovered except 
two fine scale-like discs of glistening paraffine of a diameter of 
one-sixteenth inch. These were evidently all that remained of 
the injected mass and were undoubtedly held in the innermost 
meshes of the new tissue. Immediate relief followed the oper- 



44 HYDROCARBON PROTHESES 

ation but no appreciable difference in the size of the tumor 
could be noticed. 

Cold applications or ice cloths relieve the temporary pain fol- 
lowing an injection of parafhne but in most cases this is rarely 
necessary except in extremely nervous and expectant patients. 

On the whole the author believes the secondary neuroses 
and circulatory difficulties are now practically overcome by the 
more conservative use of the matter to be injected, coupled with 
a repetition of the injection of smaller amounts at each sitting 
and not repeating the same until the first has become organized. 

18. Redness of the Skin. — Redness of the skin following an 
injection of the nature under consideration was one of the early 
objections made by various operators. 

That redness more or less permanent has been found in many 
cases in which these injections were made is true, but such red 
ness was found particularly when the injections were those of 
liquid parafhne of high melting points and in which the oper- 
ator was over-zealous in bringing about an absolute correction of a 
deformity, with the result that when the parafhne had been 
moulded and set, it was generally pinched or shaped up or out- 
ward thus causing a great deal of pressure upon the circulatory 
vessels of the skin. 

The redness in such cases did not appear until several days 
after the operation becoming worse gradually instead of bet- 
ter even in spite of the efforts to reduce it by external ap- 
plications. Not unusually, in the permanent cases, distended 
capillaries can be seen in the skin resembling the condition in 
acne rosacea chronica, especially when the injection had been 
made to correct a saddle nose. 

Smith 104 says, " Redness is present in a good many cases. 






HYDROCARBON PROTHESES 45 

I have seen a case in which the redness lasted over a year, but 
it gradually disappeared. There seems to be a tendency on the 
part of nature to take care of a foreign body, and I think the 
reinforcement of connective tissue that grows into this mass re- 
quires an increased blood supply, and later, when the blood 
supply is no longer necessary the redness will disappear." 

The latter is true where the hyperemia is either acute or 
subacute, but in chronic cases where the capillaries have become 
distended and show plainly there is little to be hoped through 
the effort of nature. 

Eckstein, 105 the advocate of " Hart-paraffine " method of high 
melting point, states that a redness of the parts develops a few 
days after the injection that disappears after a time, but that 
this redness is more marked and of longer duration when the 
injections are made intracutaneous instead of subcutaneous. 

These injections should be made subcutaneous in all cases and 
there is no excuse for deviating from this method. 

With the use of semisolid and cold paraffine mixtures as here- 
tofore advocated, redness rarely if ever follows the injection un- 
less undue pressure has been made, in which case necrosis is 
more liable to follow unless the adjacent tissue will gradually 
allow the mass to become relieved by a change in form and 
position. 

Such subsequent hyperemias are not now as common as when 
the injections were at first attempted and the author may say 
freely that they never occur when the proper method and ma- 
terial is used. 

Paget 106 says : "In a few cases — but only in a few — some 
reddening of the skin has followed the injection, and in a few 
this has been very slow to fade. 



46 HYDROCARBON PROTHESES 

" The few referred to are of a record of twenty-two nasal cases 
but no data is given whether the operator used paraffine of high 
or low melting points. F. Connell found that redness in that 
case continued for a year diminishing very little in that time. 
It appeared on the second time after the operation for a correc- 
tion of a saddle nose and remained stationary for about one 
month. Twenty drops of paraffine were injected. It very 
gradually increased, so gradually in fact, that there is still a dis- 
tinct reddened area over the bridge of the nose. On pressure 
this redness will disappear, but returns immediately after the 
removal of the pressure. A few dilated and tortuous capillaries 
course their way over the area. The condition is still present 
fourteen months after the injection. 

"There has been practically no change or decrease in the red- 
ness during the last six or seven months, it is not as marked 
as it was during the first few months, but still requires the pro- 
fuse application of face powder in order to prevent her nose 
from being conspicuously red." 

The above case has been cited because it is typical of such 
condition and while the amount as stated was quite small, one is 
almost nonplused for an explanation of the result, yet it un- 
doubtedly must have been due to a close attachment of the 
skin to the underlying structures necessitating pressure which 
is known to cause it. 

However, it is possible to have such redness develop weeks 
or months after the injections are made. In such cases it is 
not due to the primary pressure of the injection but to that 
of the newly developed tissue which has taken its place but 
which is slightly overdeveloped for the same unaccountable 
reason already referred to. 



HYDROCARBON PROTHESES 47 

Almost every surgeon who has used this method of restoring 
the contour of parts of the face has observed redness, more or 
less permanent, follow the method used but in most cases liquid 
paraffine of high melting points had been forced into the tissues 
at great pressure. 

In one case, that of a southern operator, the entire tip of the 
nose had become injected by primary diffusion or direct filling. 

It became inflamed immediately after and some weeks later, 
when the swelling had subsided, the lobule was found to be very 
hard, tense and extremely red. Two years after the author saw 
this case and the tip of the nose still appeared like a red cherry 
with numerous capillaries showing over its area, while the rest 
of the nose although much broadened by secondary displace- 
ment of the paraffine was natural in color. 

This proves that as the pressure was relieved by absorption 
and displacement, the tissue took on a normal appearance, 
whereas in the lobule of the nose, where there was no relief 
from the pressure nature could do nothing to relieve the inevit- 
able result. 

In cases where the redness is suspected it may not be too 
late, a day or two after the injection, to remould the mass into 
such form as to relieve the acute tension. 

If the redness develops early, cold applications of an anti- 
septic nature or ice cloths can be used to advantage. Anti- 
phlogistine or other similar preparations applied externally give 
good results. 

Later ichtyol, 25^ solution, may be applied ; acetate of alumen 
in saturated solution seems to do well. Some operators apply 
hydrogen peroxide, but it gives only temporary benefit. When 
the capillaries have become distended and the redness is prac- 



48 HYDROCARBON PROTHESES 

tically chronic the vessels should be destroyed with a fine elec- 
tric needle using about 20 milliamperes — direct current. 

Sometime when the redness is acute and seems to persist de- 
pletion of the part does some good. This is done by nicking 
the skin here and there with a fine bistoury and allowing the 
part to bleed freely. Care should be taken not to puncture the 
skin too deeply so as not to allow the injected mass to escape. 

In some cases it is allowable to open the filled cavity early 
and remove enough of the filling to overcome the difficulty, in- 
jecting later, after the filling has become organized to make up 
the deficiency. 

When the redness is secondary, that is when it develops after 
the connective tissue has replaced the paraffine, it is best to open 
up the part and excise enough of the tissue to overcome the 
pressure. 

In a case where the author injected for a deep furrow in the 
forehead with a cold semisolid paraffine mixture a secondary 
redness developed three months after the injection had been 
made, no redness having been noticed in the meantime. There 
was more or less swelling for two or three weeks undoubtedly 
due to pressure phlebitis which eventually subsided. 

The redness in this case was only reduced by an excision of 
the tissue causing the trouble. The result was satisfactory. 

19. Secondary Diffusion of the Injected Mass. — This is a con- 
dition that no operator can foretell, although it might be caused 
by a primary diffusion due to hyperinjection of so small an ex- 
tent that it escaped the surgeon's attention at the time. 

Again a site injected, may at the time of operation, present 
all the indications of a satisfactory result, that is, the tissues at 
the place of operation and its immediate vicinity appear perfectly 






HYDROCARBON PROTHESES 49 

loose and elastic ; the injection being made easily and the con- 
tour of the defect being remedied either partially or entirely as 
the operator may desire ; there being no mechanical anaemia 
post-operatio, and no decided effort on the part of the tissues 
to cause primary elimination after the withdrawal of the needle ; 
yet it is possible that, by such an injection, sufficient pressure 
may be caused upon some of the blood vessels within the lim- 
itations of the injection as to cause a decided reaction a few 
hours after the operation, as evidenced by a swelling, too great 
for the disturbance occasioned, and associated with all the signs 
of a fairly active inflammation. 

It is possible that such a reaction may cause a displacement 
or diffusion, post primary, of the mass injected, especially if the 
mass be merely vaseline or a mixture of vaseline and paraffine 
at a melting point too low for the purpose. Nevertheless, it is 
practically impossible to foresee such result and the operator 
can only use the same care as with any or all such injections. 

It is possible, when the reaction is too marked, to mitigate, 
to a great extent, this diffusion of the injected mass, by using 
such methods as reduce the inflammatory symptoms. 

As a rule these cases exhibit considerable ecchymosis after 
this active reaction has subsided, lasting from one to two weeks. 

Secondary diffusion, as the author uses the term, signifies an 
extension of the injected mass beyond the intended area. This 
may occur in two or three weeks or be proportionate to the ac- 
tivity of the production of fibrous connective tissue that is sup- 
planting the mass. 

Leonard Hill 107 has reported a case in which he injected 
vaseline to correct a saddle nose for esthetic or cosmetic rea- 
sons. The result was very satisfactory to both operator and 



50 HYDROCARBON PROTHESES 

patient and continued so for nearly twelve months when second- 
ary diffusion of the mass began to be noticeable. Eventually 
the diffusion became so great in the upper eyelids as to close 
both eyes completely. 

The worst case of such secondary diffusion the author has 
ever heard of or seen, came to his attention early this year. 
The patient had been subjected to a subcutaneous injection of 
oils for the cosmetic correction of an abnormal deepening of the 
inner clavicular notch. The injected mixture, as far as the au- 
thor could learn, was made up of sweet almond, peanut and 
olive oils with two others that had been forgotten. Her physi- 
cian had made two injections several days apart with a satis- 
factory result. The reaction was trifling and the parts returned 
to the normal in two weeks. 

Five months later the part injected became tender to the 
touch and began to enlarge daily. With the increase in size a 
gradual inflammation involved the whole lower region of the an- 
terior region about the root of the neck. Various applications 
were made to the part to reduce the inflammation, but at the 
end of ten days a region of skin, that had indicated the pointing 
of an abscess, burst, allowing the escape of about eight ounces of 
pus. Under the most careful surgical attention this discharge 
continued for about three months, until under the influence of 
gauze packing the wound was made to heal from the bottom 
leaving an ugly irregular scar at the site of the opening. With 
the healing of this fistular wound, however, the size of the tumor 
did not diminish whatever but continued to grow until, at the 
present time, one and a half years after the injections had been 
made, the size of this peculiar hyperplastic growth of ovate form 
measures nearly five inches across its horizontal diameter and 



HYDROCARBON PROTHESES 51 

three and one-half inches through the vertical. It is closely 
adherent to the overlying thickened skin, which has undergone 
a yellow pigmentary change to be considered in the next text 
subdivision. The tumor is hard, painless and freely movable 
beyond the limitation of its skin attachment and rests upon the 
sternal thirds of the clavicles, extending upward and forward 
with evidences of traction on the whole anterior skin of the neck. 
Laryngoscocy discloses nothing abnormal. The deformity is 
hideous and necessitates a mode of dress to conceal it. The 
patient has not as yet been operated on for the extirpation of 
the growth, owing to her present physical condition, the result 
of melancholia. 

Scanes-Spicer 108 injected some vaseline to correct a saddle 
nose with satisfactory immediate result, but after several days, 
the upper lids became slightly cedematous and soon after a small 
hard lump, the size of a grain of shot, was felt in the left upper 
lid. 

Harmon Smith 109 observed a secondary diffusion in two cases 
in which the abnormality in one occurred on the side of the nose 
and in the other at the inner canthus following the course of 
the angular vein. 

While in the foregoing cases the difficulty may have been 
overcome by using the cold, semisolid paraffine mixture and re- 
ducing the amount injected, it is questionable if the diffusion 
could thus have been entirely overcome. 

The author points to the fact that undoubtedly this fault is 
observed more when the tissues at the side of the nose, or about 
the alae, are injected and that the cause here is one of an un- 
equal pressure of the parts — the skin more or less bound down 
above and the ungiving cartilage below. 



52 HYDROCARBON PROTHESES 

In such cases great care should be exercised in the amount 
injected and if, after introducing the needle, the tissue be found 
to be unduly adherent and inelastic, to withdraw the needle and 
with a fine tenotome divide or dissect up the skin before the 
mass is injected. At no time would an operator be justified to 
inject more than ten drops of the mass, at a single operation, 
into the parts referred to. 

As already mentioned, there is not only danger of diffusion 
of the mass in such region of the nose, including the lobule 
and the sub-septum, but there is a special danger of gangrene 
from pressure where the tissues are less supportative than where 
muscular tissue or greater mobility of the skin is found. 

After the immediate attempts to reduce a reactive inflamma- 
tion, nothing can be done to overcome secondary diffusion ex- 
cept excision of the amount not wanted. This should not be 
undertaken until at least three months after the time of injec- 
tion. 

The mass of connective tissue must be entirely excised as 
thoroughly as possible, and slightly beyond the border of the 
abnormal elevation. A sharp curette is practically of no use 
for this purpose and only wounds the skin, and by reason of re- 
tentive shreds of tissue may cause infective inflammation. 

The opening into the skin should be made with a fine bistoury, 
the skin be dissected off from the elevated connective tissue 
and the latter extirpated by dipping cuts of a fine small, sharp - 
pointed, half-rounded scissors. The operation can be done 
neatly and painlessly under Eucaine anesthesia. 

The wound may be sutured with fine silk or be allowed to 
unite of its own accord. 

It is advisable to supply a small pressure dressing, made of a 



HYDROCARBON PROTHESES 53 

circular gauze pad, over the site to assure of the best union be- 
tween the dissected or undersurface of the skin and the floor of 
the wound. 

Dry dressings are to be preferred, since moisture would tend 
to soften the skin and permit it to crawl which would not im- 
prove the ultimate result. 

20. Hyperplasia of the Connective Tissue Following the Or- 
ganization of the Injected Matter. — The overproduction of con- 
nective tissue replacing the injected mass is rarely observed, yet 
a few cases have been noted. 

Sebileau no has reported a true case of diffuse fibromatosis 
following an injection of paraffine. This not only included 
the site of the injection, but extended to the surrounding or ad- 
jacent tissue, making the secondary defect much more disfigur- 
ing than the first. 

The author has observed one case of such an hyperplasia fol- 
lowing the correction of a saddle nose. The area injected pre- 
sented no unusual appearance for six months when the nose at 
its middle third began to enlarge slowly until it resembled a 
marked Roman shape, the enlargement extending laterally and 
as far down as the nasogenian furrows at the end of nine months. 

The injection used was a cold, semisolid paraffine mixture 
and only sufficient to barely correct the defect was injected, the 
skin being thoroughly flexible at the time of operation. 

No reason can, therefore, be given for this unusual result, ex- 
cept, perhaps, a peculiar idiosyncrasy of the tissues, that may 
be compared, somewhat, with the external tissue changes in 
hypertrophic or keloidal scars, especially noted in the wounds 
of negroes — a condition for which we have, as yet, found no at- 
tributable cause. 



54 HYDROCARBON PROTHESES 

While we cannot definitely prevent such a result, following 
an injection of a hydrocarbon, we may at least be sure that 
hyperinjection is not the cause. 

Once the hyperplasia is established the surgeon must simply 
wait until he believes the activity of the abnormal growth has 
subsided and then remove the superabundant tissue with the 
knife. 

With another case, in which the patient was operated on by 
another surgeon, the author was called upon to remove the 
growth. A part of the coarse, yellowish pale and cartilage like 
tissue was excised, sufficient to restore the parts to a normal 
contour. After an uneventful recovery the patient went away, 
greatly pleased, only to return in six months, presenting a 
similar condition as before the extirpation. 

A second operation was done, this time more extensively, the 
entire yellowish connective tissue being removed by the aid of 
a long median incision on the anterior aspect of the nose. 

The wound healed readily and showed very little scar and 
the patient was discharged. One year after the last operation 
the nose was still normal in appearance and the growth had not 
reappeared. 

From this it is deemed absolutely necessary to remove prac- 
tically all of the newly formed tissue to warrant a nonrecurrence 
of the fibromatosis. 

21. A Yellow Appearance and Thickening of the Skin after 
Organization of the Injected Mass has taken Place. — This condi- 
tion of the skin is evidenced sometime after the injected mass 
has become organized, beginning about the sixth month after the 
time of injection. It has been especially noticed with the hard 
paraffine fillings of the nose but also with other injections, even 



HYDROCARBON PROTHESES 55 

of the lowest melting points, about the sterno-clavicular regions 
of the neck. 

The skin becomes at first streaked with a superficial and ir- 
regularly defined patch of red, the forerunning indication of the 
size of the ultimate pathological change. The red color sub- 
sides slowly leaving the area pale which thereafter gradually 
thickens taking on the appearance of a light yellow stain in the 
skin. 

Practically opposite to the condition in xanthalasma, where 
the yellow area is slightly elevated and occurs in the loose tis- 
sue of the eyelids. 

The cause seems to be a degenerative change in the skin de- 
pendant on pressure upon its underlying tissues. Evidently 
the pressure of an overproduction of the connective tissue which 
has sprung up to replace the injected mass. 

Seemingly the cause is due to an injection being made too 
close to the derma where the latter is bound down to the sub- 
cutaneous tissue, or a desire on the part of the surgeon to pre- 
vent an injection into the deeper areolar tissue, especially when 
the injection is made in the vicinity of the larger blood vessels 
for fear of causing embolisms or phlebitis. 

Excluding the use of hard parafrme for such injection, the 
operator should be sufficiently experienced to use these injec- 
tions properly and without fear, and at all times avoid injecting 
into the skin instead of subcutaneously. 

Making the puncture first and observing if blood flows freely 
or trickles from the detached needle will assure the operator 
into what tissues he has thrust his needle. 

Should active bleeding follow the puncture, he should with- 
draw the needle and wait to inject the site at a later sitting, 



56 HYDROCARBON PROTHESES 

using the same precaution ; at no time should he be in doubt 
as to the absolute placing of the injected mass. 

When the injections are done about the lower neck or shoul- 
ders great care must be exercised to avoid the blood vessels, and 
small quantities be only injected to prevent reactions that may 
cause phlebitis of these vessels ; furthermore the injected mass 
must be carefully moulded to prevent the formation of uneven 
elevations or lumps. Without doubt an injection into one of 
the blood vessels of the neck would mean certain death. 

Kofman in lost a patient by pulmonary embolism 24 hours 
after an injection of 10 cubic centimeters of paraffine. How 
many punctures he made to inject this amount is not stated, but 
certain it must be that he introduced part of the mass directly 
into some blood vessel. 

The author advises, when injecting about the neck, to use a 
stout, dull pointed needle introduced under local ethyl chloride 
anesthesia and to elevate the tissue with the needle as the in- 
jection is made. In this way the operator can observe the be- 
havior or placing of the injected mass, at the same time stretch- 
ing the skin to permit of the injection without encroaching upon 
the blood vessels. The mass is immediately moulded after each 
injection. The further question of the practical method of mak- 
ing these injections will be fully considered later. 

If, however, the pigmentation under consideration has taken 
place, electrolysis with a fine needle may be resorted to, with the 
object of whitening the discoloration by producing scar tissue, 
in the form of punctations, in the discolored area. 

While the numerous white spots so caused are objectionable, 
they are better borne by patients than the pigmented appear- 
ance. A thorough needling of the spot in this way eventually 



HYDROCARBON PROTHESES 57 

brings about an improvement and if, for esthetic reasons, the 
patient objects to the unsightliness of the result thus obtained 
the white area may be carefully tattooed with an appropriate 
color to match the rest of the skin of the face or neck. 

If the pigmented area is not too large, it can be excised with 
the knife and the healthy skin be brought together with a 
fine silk suture, thus leaving a thin linear scar which can be 
dealt with as the punctate scar area, if desired ; the electroylsis 
being a painful procedure at all times, since sufficient milliam- 
peres must be used to cause scar tissue formation, which is be- 
tween twenty to thirty milliamperes in such cases. 

22. The Breaking Down of Tissue and Resultant Abscess Due 
to the Pressure of the Injected Mass upon the Adjacent Tissue 
after the Injection has become Organized. 

The above result is particularly noticeable when the injections 
have been made into the cheek or the breast. It is understood 
that the suppurative changes under consideration herein are not 
attributable to imperfect sterilization of the injected matter, al- 
though it is possible, and perhaps is the cause in $0% of the sup- 
purative elimination of the injected mass from the cheek, that a 
nucleus of infection is carried into the tissues and is held in 
suspense for a time, because of its imbedment in a neutral me- 
dia that does not readily permit of bacteriological propagation, 
but eventually this nucleus must come in contact with tissue 
which it can affect, and only then may its infection be taken 
up. 

The author believes that such secondary affections are ac- 
countable to pressure effects upon the blood vessels or glandular 
structure, as in the case of breast injections, the new con- 
nective tissue causing a lack of nourishment in the part or 



58 HYDROCARBON PROTHESES 

gland, and a resultant breaking down of the tissue, directly in- 
fluenced in some instances by external violence. 

Tuffier 112 reports the elimination of paraffine injected into 
the breast several weeks after the injection. If this elimination 
had been caused by primary infection an acute reaction would 
have taken place at least within forty-eight hours, ending in 
abscess shortly after. 

A case which came to the author's attention was that of a 
lady who had been operated upon for the correction of a saddle 
nose three months before. The result had been satisfactory. 
The day previous to consulting the author she had injured her 
nose in an automobile accident. The nose was much swollen, 
very painful and red over the entire upper and middle third. 
The use of external cold did not relieve the condition much and 
on the fourth day the skin broke open at one point allowing 
pieces of the paraffine to escape. Immediate relief followed, 
the wound healed with a marked sinking of the middle third of 
the nose. After three weeks the nose was again injected with 
no further untoward symptoms, the result being satisfactory for 
two years past. 

In this case undoubtedly the exciting cause was directly due 
to violence, which may be the forerunner in many of such cases, 
but there is a number of such eliminations directly due to a 
breaking down of the tissue from internal pressure alone. 

There is no way to overcome this difficulty, except to await 
the definite formation of the abscess and then to puncture the 
skin directly over the soft fluctuating area and to drain the cavity. 

Once relieved, the condition quickly subsides, leaving a cer- 
tain amount of loss of contour, which can however be corrected 
several weeks after by a secondary injection. 



HYDROCARBON PROTHESES 59 

When the abscess occurs in the cheek it is not advisable to 
open interiorly, but to make the puncture through the skin, on 
account of the danger of infection from the buccal cavity and 
of the imperfect evacuation thus attained. 

A trocar and canula of proper size will be found to be the 
most suitable, the parts being gently manipulated to evacuate 
the contents of the abscess. 

Aspiration can also be resorted to, but for the breast a small 
linear incision, made under local anesthesia at the most depend- 
ant point, best answers the purpose. 

A small gauze strip drain may be employed for a few days to 
insure of perfect drainage in the latter case, the wound being 
brought together eventually by a delicate cosmetic operation if 
desirable. 



THE PROPER INSTRUMENTS FOR THE SUBCUTANEOUS 
INJECTION OF HYDROCARBON PROTHESES 

Although Gersuny 113 advocated the use of a Pravaz syringe 
for injecting the liquified vaseline mixture for prothetic pur- 
poses, it was soon found that such an instrument was practic- 
ally useless, especially when the parts to be injected offered 
more or less resistance to the introduction of the foreign mat- 
ter. 

Other operators, following the advice of Eckstein, 114 who ad- 
vised the employment of " Hart paraffine " of high melting point 
liquified by heat, raised the objection that, the metal needle be- 
came so easily obstructed by the rapid setting of the paraffine 
in its distal end that, the great force necessary to eject the con- 
tents of the syringe usually resulted in a breakage of the glass 
barrel in the hands of the operator or as in some types of the 
syringe a separation of needle and syringe at the point where 
the former was slipped upon the ground point of the latter, 
with the annoyance of the paraffine squirting over the faces of 
both patient and operator. 

Eckstein tells us how to overcome the first difficulty with this 
same style of syringe as used by him. He covers the syringe 
with a rubber insulating sleeve and draws several drops of hot, 
sterilized water into the needle to overcome the plugging up of 
the latter ; an illustration of his syringe has been shown on 



HYDROCARBON PROTHESES 61 

page 26. Mention has also been made of the various methods 
used to overcome this difficulty by other operators. 

It was presently found that such an instrument was not only 
impractical but also a detriment to procuring desirable results, 
the paraffine solution shooting out suddenly, in some instances 
causing hyperinjection, and at other times emerging so slowly, 
that it required unusual force on the part of the operator — a 
painful procedure for delicate hands inasmuch as the fingers 
only can be applied to operate the instrument. 

With the object of overcoming this uncertainty of the amount 
of the injection and the unnecessary exertion to inject any given 
quantity, as well as to establish enough vice a tergo to keep the 
needle free from plugging up with cooling paraffine, various op- 
erators devised instruments, all having practically similar points 
of mechanical merit and usefulness. The required necessities 
being to invent a syringe which would have a known capacity, a 
piston under control of the operator at all times, and metallic 
needles of proper lumen, to prevent the solidification of the 
liquid paraffine, screwed to the syringe to prevent loosening. 

With the object of overcoming these difficulties the author 
devised a syringe which was made for him by Tieman & Co., 
early in 1902. He begs to introduce the same here, as a type 
similar to which most operators have built their special instru- 
ment. 

The syringe at that time consisted of a glass barrel, of a size 
to hold 6 c. c. of liquified paraffine. At either end of the 
barrel tube were placed metal ends, the distal one containing a 
cap with a screw thread to receive the needle, the upper cap 
being threaded to receive a check nut through its center and on 
its outer surface, on opposite sides to each other, two metallic 



62 HYDROCARBON PROTHESES 

rings to accommodate the thumb and forefinger. The center 
of the check nut was double threaded to receive the piston rod ; 
the piston or plunger being held in place by two, upper and 
lower washer nuts, the lower being threaded to receive a small 
rod passing through the bored out center of the piston rod, and 
which ended in a check nut, in the handle, threaded upon the 
outer or manual end of the piston rod, in such a way that the 
fibre or asbestos piston washer could be tightened and loosened 
at will. 

The syringe permitted of being used as an ordinary syringe 
by unscrewing the cap check nut or be made into a screw drop 
syringe by screwing the same nut into place. By turning the 
handle end of the piston rod the contents of the syringe were 
forced out smoothly and evenly in any quantity desired. 

With the later employment of the cold, semisolid preparation 
of vaseline and parafnne, as heretofore considered, it was found 
necessary to reinforce this syringe so that the greater pressure 
necessary to eliminate the worm-like thread of hydrocarbon would 
not force off the lower cap or break the barrel of the syringe at 
its needle end. 

This was done for the author by the Kny-Scheerer Co., Dec. 6, 
1902, when metallic strips were added to opposite sides of the 
glass barrel connecting the lower with the upper cap. 

The instrument as then made is shown in Fig. V. 

At the same time the same firm made the author a syringe 
entirely of metal, similar in construction, except that the barrel 
was made larger in diameter and shorter in proportion to bring 
the instrument near to the seat of operation. The regulating 
washer rod was not needed, since in this instrument no washers 
were required the piston head being made of solid metal through- 



HYDROCARBON PROTHESES 



63 



out and the rod being soldered to the plunger, thus overcoming 
any objectionable fault in sterilization. 

This type of syringe was found to be most suitable for the 




Fig. V. Kolle Screw Drop Syringe. 

cold, semisolid injections and is of the type now universally 
used except for the slight modifications of the various operators. 
It is illustrated in Fig. VI. 




Fig. VI. Kolle All Metal Screw Drop Syringe. 

Since there were no objections to making the barrel large 
enough to permit of injections, such as are required for restoring 
the contour of the cheek and the neck and shoulder, it was 



64 HYDROCARBON PROTHESES 

made to contain 10 cubic centimeters working capacity, over- 
coming the necessity of constant refilling, when comparatively 
large injections had to be made — a fact worth remembering 
from a practical standpoint, although two or three of these syr- 
inges specially prepared for each patient, might be found de- 
sirable by some operators. Yet the simplicity and ready facility 
with which this instrument can be used and refilled renders it 
useful and sufficient for performing operations of this nature to 
any judicious extent. 

Syringes holding small quantities of the parafhne mixture are 
found to be a nuisance. 

The following operators employ syringes of the capacity 
given : 

Brceckaert 115 3 c. c. 50 m. m. 

Eckstein 116 5 c. c. 80 m. m. 

Freeman 117 5.6 c. c. 90 m. m. 

Downie 118 10 c. c. 150 m. m. 

The instrument employed by Brceckaert, holding less than 
one dram, would be of little use except to correct very slight 
deformities about the brow or nose, or dressing up or complet- 
ing the contour of parts previously filled by larger injections. 

Another syringe similar in type to the author's, but of a ca- 
pacity of 5.6. c. c. was introduced by Harmon Smith. 119 

The principles of the syringe are alike, but the style of 
handles, two flat metal bars at opposite sides, offers an objec- 
tion when comparatively hard mixtures of paraffine and vaseline 
are used. 

While operating the syringe the narrow blades are brought 



HYDROCARBON PROTHESES 



65 



in contact with the soft flexor sides of the thumb and forefinger, 
indenting the flesh deeply and with the least unexpected move 
on the part of the patient permitting it to slip out of the grasp of 
the surgeon. Its incapacity for large injections also offers some 
objection, but for correcting smaller defects it is both prac- 
tical and compact. It is illustrated in Fig. VII. 

It is obvious that with the screw drop type of syringe the 
cold semisolid paraffine mixture contained in its barrel is always 
under the full command of the operator, nor can there be a 
plugging of the needle since the great force that can be exerted 




Fig. VII. Smith's Screw Drop Syringe. 



with a turn of the piston handle would free it, even if the mix- 
ture were of a comparatively high melting point, although the 
force to be applied would naturally increase in proportion to the 
hardness of the mass within the syringe. 

The turning of the screw piston forces out the contents of 
the syringe in the form of a white thread of a diameter equal 
to the diameter of the lumen of the needle. 

To facilitate this ejection, the needles should be of ample 
diameter, not over one inch long and having knife edged points. 



66 HYDROCARBON PROTHESES 

Longer needles are not necessary and only add to the force re- 
quired to turn the screw handle. 

Curved needles, used by some operators, are never needed 
and the author does not see how they could be applied at any 
time in preference to the straight. 

As much of the paraffine mixture can be forced out of the 
syringe as may be desired by screwing the piston down into the 
barrel. 

The piston rod may be graduated in five or ten drop divisions, 
but the operator rarely ever refers to the scale. He judges the 
amount required by the elevation of the tissues brought about 
by the presence of the paraffine thus forced under the tissue. 
Experience soon teaches him the amounts necessary or judi- 
cious in each case, always remembering that it is better to do a 
second and later injection than to hyperinject. 

The entire instrument being of metal, permits it to be steril- 
ized as readily and in the same manner as any other metallic 
instrument. 

It is understood that the syringe must be taken apart for 
sterilization at all times. 

Lubrication, to facilitate operation, is never required since the 
nature of the mixture used in the syringe answers this purpose 
in every way. 

Owing to the greater amount of metal in the solid piston it- 
self the latter is very likely to expand under dry heat steriliza- 
tion or boiling, so much so, that for a moment it cannot be in- 
troduced within the barrel. This can be quickly overcome by 
dipping it into cold sterile water or absolute alcohol which brings 
about its contraction. 

After using, the syringe should be emptied entirely, unscrewed 



HYDROCARBON PROTHESES 67 

and sterilized and placed in the metal case furnished for it. A 
screw cap is furnished to take the place of the needle when not 
in use. 

The method of filling and using the syringe will be considered 
later. 



PREPARATION OF THE SITE OF OPERATION 

The same surgical precautions should be observed when a 
paraffine injection is to be undertaken as with a minor surgical 
operation. 

It is hardly found necessary to prepare the site of operation 
the day before, nor need the patient be detained for such time 
for the purpose of making him ready. 

With careful observance of ordinary surgical technic, both as 
to surgeon and patient, all of this class of operations can be 
performed in any physician's office, providing that both in- 
struments and the mass to be injected have been rendered 
sterile. 

Especial care should be given to the operator's hands, for 
with these he not only handles the instruments but must also 
mould the mass injected, thus frequently coming in contact with 
the needle opening or openings made in the skin. 

When injections are to be made in the cheeks of the patient, 
the mouth should be prepared by cleansing the teeth thor- 
oughly and washing out the buccal cavity with warm boric acid 
or hydrogen peroxide "solution, or any of the preparations of 
the Listerine composition. 

This rinsing should be continued every few minutes for at 
least ten minutes before the operation is undertaken. 

This is necessary as the surgeon must introduce his finger 



HYDROCARBON PROTHESES 69 

into the mouth and behind the cheek to mould out the mass in- 
jected subcutaneously and infection could easily be introduced 
by his fingers during this procedure. 

Externally a generous field of the operation is scrubbed with 
a brush dipped into green soap and water. 

The skin is then thoroughly washed with gauze sponges 
steeped in absolute alcohol, followed with spongings with a 
1 : 5000 solution of bichloride of mercury. The whole surface 
is then wiped off with a sponge dipped in ether and covered 
for the time being with a pad of sterilized gauze until the oper- 
ator is ready to proceed with the operation. 



PREPARATION OF THE INSTRUMENTS FOR OPERATION 

The manner of preparing the necessary mixture of paraffine 
has been described on p. 39. After such preparation, the mix- 
ture, still hot, may be poured into test tubes which are sealed 
and put away for further use, each tube holding just enough to 
fill the syringe two-thirds full. 

When a syringe is to be filled, one of the tubes is opened and 
the contents are again boiled over a spirit flame, or simply liq- 
uified and poured into one of the types of heaters already de- 
scribed for the same purpose of resterilization. 

From the test tubes or the heater, the boiling mixture may 
be drawn up into the sterilized syringe to the required amount 
or it may be poured into the opened piston screw cap end. 

In the latter event the ready cooling of the mixture as it en- 
ters the needle will permit it to be retained in the barrel, or 
the needle may be immersed in sterile water as the paraffine is 
poured into the syringe, yet even if a few drops escape from 
the needle in the former method, no harm is done, as such loss 
amounts to nothing and helps to eventually fill the syringe 
evenly and free of air. 

If the mixture is drawn up into the barrel to the required 
height, more or less air enters, which must be removed by turn- 
ing the syringe, needle up, and screwing up the piston rod until 
either the liquid or cylindrical thread of the cooled mixture ap- 
pears. 



HYDROCARBON PROTHESES 71 

If the mixture is poured into the syringe the piston is slowly 
pressed into the barrel, thus allowing the air to escape along 
its sides if the mixture is set, or if warm the syringe is turned 
up and the piston screwed into place. As this is done the few 
drops of cooled paraffine will be forced from the needle before 
the air is exhausted. The screw is turned until the paraffine 
emerges evenly from the needle. 

The syringe must now be laid aside, or placed in sterile 
water of the temperature of the room, to allow the liquid within 
to set evenly and become uniform in consistency. 

The operator will follow what method he pleases in filling 
his syringe, but at no time should he fill it with the cooled prod- 
uct with a spatula, or other such means, as he is sure to fill it 
unevenly in this way, incorporating a number of air spaces. The 
air issues from time to time during an operation with sudden 
sputtering outbursts, that not only tend to annoy the patient 
but also to frighten him — the shock being unusual and unex- 
pected, while the air thus forced into the subcutaneous tissues 
puffs out the parts and interferes with a perception of the proper 
amount to be injected and adds to the danger of air embolisms. 

Slipshod methods are inexcusable and should not be tol- 
erated. The best results possible should be given the patient, 
and only from the best results obtained with the best care can 
the most reliable data be attained, all helping to fix the relia- 
bility, efficacy and exactitude of this branch of cosmetic surgery. 



THE PRACTICAL TECHNIC 

The field of operation and the instruments having been prop- 
erly prepared as described the modus operandi must next be 
considered. 

Since the various parts of the face to be injected demand 
specific procedure they will be considered somewhat individu- 
ally hereafter, whereas the general technic, applicable in as far as 
the method of injection is concerned and applying similarly in 
all cases, may tersely be first taken up. 

Various and noted surgeons point out that these subcutane- 
ous injections should be made under general anesthesia, i. e., 
ether, while others consider the hypodermic use of cocaine or 
eucaine ft solution in i to 4% necessary to accomplish good 
results. 

The author considers the method in the first case objection- 
able both as to patient and operator entailing much discomfort 
to the one operated on and demanding an unnecessary waste of 
time for the etherizing and recovery. Likewise is the employ- 
ment of a local anesthetic not indicated nor demanded, since 
the operation to be undertaken necessitates only the pain as- 
sociated with the prick of the needle through the skin. 

The objection to etherization is obvious, while the hypoder- 
mic employment of any local anesthetic, by the very fact of its 
presence of volume and its physiological action upon the tissue, 



HYDROCARBON PROTHESES 73 

tends to interfere with the proper injection of the parts by rea- 
son of temporary swelling of the parts, not caused by the later 
injections of the prothetic mass. 

If in nervous irritable patients an anesthetic is required to al- 
lay fear it is best to use the ethyl chloride spray upon the skin 
sufficiently to overcome the sharp sting of the needle insertion. 
For this purpose the ether spray is used only to the point of 
blanching the skin and no longer. 

This mode of procedure is especially useful when a number 
of injections are to be made, as in the rounding out of a cheek 
or of the shoulders, in which the contour cannot be restored 
from one point of injection as will hereinafter be described. 

The patient being now in readiness, the skin over the area is 
lifted or pinched up with the fingers of the left hand of the op- 
erator as a guide to its mobility and to steady the part. 

The point of the needle is now forced through the skin and 
into the subcutaneous tissue at a point along the periphery of 
the deformity and pushed a little beyond the center of the 
cavity to be filled. 

The elevation of the skin is in the meantime partly kept up 
with the needle itself, while the syringe is grasped with the freed 
hand, the thumb and forefinger of the right hand being placed 
upon the handle of the screw or piston rod which they must 
rotate to force the semisolid mass from the instrument. 

Before beginning the injection an assistant is instructed to 
press with his fingers the tissue about the margin of the defect 
to prevent the filling from becoming misplaced or being forced 
into undesirable channels especially if the skin over the defect 
is found to be thick and inelastic. 

The screw handle is now rotated evenly and slowly, dis- 



74 HYDROCARBON PROTHESES 

charging the mass to be injected which will soon be evidenced 
by the rise of the skin over the depression to be corrected. 

Only sufficient of the mass must be injected to fairly correct, 
never to overcorrect, the defect. 

Experience alone will assure the surgeon when this point has 
been attained, since he cannot immediately judge the necessary 
amount injected as it will appear as a round or irregular lump un- 
der the skin, until it has been moulded or worked out into shape. 

Owing to the pressure exerted upon the contents of the 
syringe, which will continue to emerge from the needle for a 
time, the needle is left in place for a few seconds before with- 
drawal, so that the needle canal through the skin will not be- 
come filled with the semisolid mixture. 

Such blocking up of the opening causes a cystic development 
or enlargment about the opening in the skin by this backing up 
or exuding, ofttimes crowding itself in between the layers of the 
skin and necessitating later removal with the knife. If not this 
fault it tends to keep the wound open unnecessarily after the 
operation preventing healing and permitting the escape of a cer- 
tain amount of the injected mass, if a mixture of low melting 
point has been utilized. 

The needle, having been allowed to remain as advised, is now 
withdrawn. The tip of one finger is placed over the opening 
in the skin and held there gently, but firmly, while the mass is 
moulded into the shape required or desired with the fingers of 
the right hand. 

If it now appears that the injection is insufficient the needle 
may again be introduced through the same opening and more 
is injected, remembering, however, that if the correction is quite 
normal no more should be added for several days, or until the 



HYDROCARBON PROTHESES 75 

injected mass has become organized, which should take place in 
about three weeks. 

If it is found that the skin over the defect is inflexible and 
bound down it will be found advisable to sever or disect sub- 
cutaneously the adhesions that bind it down with the use of a 
fine tenotone or a spear-headed paracentesis knife. 

This may be done two or three days before the parts are in- 
jected to assure the surgeon of an absolute cleanliness of the 
wound. 

Mayo 120 advocates the injection of a saline solution into sub- 
cutaneous wounds thus made as a guide to the extent of dis- 
section and to further loosen the tissues. 

When the parts, thus loosened, show little tendency to bleed 
the author advocates immediate injection, as the waiting for 
several days permits the throwing out of new connective tissue 
cells that interfere to a certain extent with the proper injection 
of the part. 

It is with such wounds that secondary elimination is most 
likely to take place, especially if " Hart paraffin e " or paraffine 
of a high melting point has been employed. 

This is undoubtedly due to the healing down and contraction 
of the margins of the wound which seems to progress more and 
more, encroaching eventually upon the hard mass and ending in 
inflammation of the overlying skin and ultimate illimination. 
With injections of softer consistency this is less frequent and, 
in fact, may be entirely overcome by limiting the amount of the 
injection at the first sitting, relying upon a full correction for 
later operations, when the periphery of the wound has become 
more or less influenced by the presence of the neutral mass be- 
tween the wounded surfaces. 



76 HYDROCARBON PROTHESES 

The subcutaneous dissection referred to must, of course, 
be done under local anesthesia, preferably the Schleich mixture 
or a i% solution of Eucaine ft. 

The injection of the paraffine, or hydrocarbon mixture, in 
semisolid form, having been made and properly moulded into 
shape, is set or fixed by spraying the part with ether or by 
the application of sterile ice cloths. When liquid paraffine has 
been injected it will be noted that the paraffine in setting con- 
tracts upon itself considerably leaving less of a correction than 
anticipated. 

The needle opening in the skin is next washed off with a 25% 
solution of hydrogen peroxide and closed over with a drop of 
collodion. 

The patient may then be discharged for the time being, with 
the instruction to apply ice cloths to the part for at least twelve 
hours to reduce, as far as possible, the reactive resultant inflam- 
mation. 

On the third day the collodion patch may be removed and re- 
placed with isinglass adhesive plaster applied with an antiseptic 
solution. The latter is allowed to remain on the skin until it 
falls off. 



SPECIFIC CLASSIFICATION FOR THE EMPLOY- 
MENT AND INDICATION OF HYDROCARBON 
PROTHESES ABOUT THE FACE 

Reference has been made heretofore to the general indications 
for which subcutaneous injections of paraffine or its compounds 
may be employed. With the object of systematizing such indi- 
cations and to further bring out the practicability and judicious 
use of the method under consideration the author submits the 
following tabulated arrangement, with the hope that it may lead 
to a more concise and better knowledge of the possibilities 
within the reach of the plastic or cosmetic surgeon. 

The face will be considered in such grand divisions as are 
easily and readily understood, the defects of each part being 
shown under its distinctive regional heading. 

DEFORMITIES ABOUT THE FOREHEAD 

Punctate. 



Transverse Depressions 

^ Linear. 

Deficient or Receding Forehead : 

(Exhibition of Undue Superciliary Ridges). 

f Traumatic. 
Unilateral Deficiency -l 

I Surgical (Frontal Sinus). 



78 



HYDROCARBON PROTHESES 



Inter-ciliary Furrow 



Temporal Muscular Deficiency 



f Single. 
I Multiple. 



Unilateral. 
Bilateral. 



DEFORMITIES OF THE NOSE 



r Superior third. 
Middle 
Inferior " 
Superior half. 
Inferior " 
Total. 



Anterior Nasal Deficiency 



Lateral Insufficiency 

Lobular Insufficiency. 
Inter-lobular Deficiency. 

Alar Deficiency 
Subseptal Deficiency 



Unilateral. 
Bilateral. 



f Unilateral. 
1 Bilateral. 

f Partial. 



I Complete. 



HYDROCARBON PROTHESES 



79 



DEFORMITIES ABOUT THE MOUTH 




< 


f Unilateral. 




Upper Lip ^ Median. 






1^ Bilateral. 


Labial Deficiency < 




f Unilateral. 




Lower 


Lip \ Median. 






(^ Bilateral. 


Naso-labial Furrow- 


| Unilateral. 
[^ Bilateral. 


Oral Angular Furrow 


( Unilateral. 
I Bilateral. 


DEFORMITIES ABOUT THE CHEEKS 




Total 


f Unilateral. 
[ Bilateral. 


Deficiency of Cheek -< 




v. 




Partial 


j Unilateral. 
1 Bilateral. 


DEFORMITIES ABOUT THE ORBIT 


Deficiency of Lid 
Contour 


f Unilateral. 
Upper Lid \ 

i Bilateral. 

f Unilateral. 
Lower Lid \ 

1 Bilateral. 



80 HYDROCARBON PROTHESES 

I Unilateral. 
Furrow About Canthus *l 

I Bilateral. 

f Unilateral. 
Deficiency of Ocular Stump -| 

I Bilateral. 



DEFORMITIES ABOUT THE CHIN 

Anterior Mental Deficiency 



f Partial. 

I 



Total. 

Lateral Mental or Angular f Unilateral. 

Deficiency [^ Bilateral. 

DEFORMITIES ABOUT THE EAR 

f Unilateral. 
Pro-auricular Deficiency J 

I Bilateral. 

f Unilateral. 
Post-auricular Deficiency -J 

I Bilateral. 

SPECIFIC CLASSIFICATION FOR THE EMPLOY- 
MENT AND INDICATION OF HYDROCARBON 
PROTHESES ABOUT THE SHOULDERS, ETC. 

( Unilateral. 
Supraclavicular Deficiency X 



HYDROCARBON PROTHESES 



81 



Infraclavicular Deficiency 
Interclavicular (Notch) Deficiency 
Supra-acromion Deficiency 
Infra-acromion 
Supra-mammary Deficiency 



Mammary Defi- 
ciency 



Partial 



Total 



Supra-Spinous Deficiency 



Infra-Spinous Deficiency 



f Unilateral. 
(^ Bilateral. 



f Unilateral. 



I Bilateral. 

f Unilateral. 
Bilateral. 

( Unilateral. 
Bilateral. 

Unilateral, 
i Bilateral. 

Unilateral. 
[^ Bilateral. 
Unilateral. 
Bilateral. 

Unilateral. 
Bilateral. 



Interscapular Deficiency 



SPECIFIC TECHNIC FOR THE CORRECTION OF 
REGIONAL DEFORMITIES ABOUT THE FACE 
AND SHOULDERS 

DEFORMITIES ABOUT THE FACE 
TRANSVERSE DEPRESSIONS 

Punctate Form. — Such deficiencies are either of sharply de- 
fined depressions in a part of the frontal bone due to congen- 
ital malformation or of traumatic origin. 

In the first instance, they are usually unilateral or median 
and rarely ever bilateral. In those of the second class the de- 
formity may be median but is more often found to be unilateral. 

Linear Depressions of the forehead are usually found to be 
congenital, although traumatism in the form of direct violence 
may be the cause, as for instance the kick from a horse or a se- 
vere blow or fall. 

The acquired linear form of lack of contour is found in people 
of middle life given to undue use or corrugation of the fore- 
head, as in frowning. 

The correction of this class of deformities may be accom- 
plished by carefully raising the depressed area by repeated in- 
jections of small quantities, always avoiding the frontal and 
supraorbital vessels. 

At no time should such a deformity be corrected in one sit- 



HYDROCARBON PROTHESES 83 

ting, unless when the defect is a congenital one of small mo- 
ment. 

The reaction following these injections, owing to the close 
attachment of the integument to the bone, is usually found to 
be more severe than where the skin is more loosely attached. 

In traumatic cases the scar attachments should be freely lib- 
erated, under eucaine anesthesia, by the aid of a fine probe- 
pointed tenotome, before the cold paraffine mixture is introduced. 

In such event only one opening should be made and just 
enough of the mixture be injected to raise the skin to its nor- 
mal contour, if this be possible. Generally, later injections are 
required and these may be made without further dissection. 
They should not be undertaken until the incised wound made 
with the tenotome has healed thoroughly, otherwise the pres- 
sure of the injection is liable to burst through the delicately 
healed wound and thus delay if not endanger the success of the 
first operation. 

When the reaction following such injections be severe asso- 
ciated with considerable oedema, cold pack or ice cloths should 
be applied or resort may be had to hot applications of antiphlo- 
gistine. The patient should be kept on his feet during the day 
and sleep with the head high at night. The bowels should be 
kept open and general tonics be given if indicated. The pa- 
tient usually returns to the normal, except for a little tenderness 
about the forehead, in three or four days under the treatment 
outlined. 

DEFICIENT OR RECEDING FOREHEAD 

In this condition there is usually a transverse lack of contour 
across the forehead above the superciliary ridges giving the 



84 HYDROCARBON PROTHESES 

patient a degenerate appearance. The defect is congenital and 
is to be corrected as described in the foregoing division, al- 
though the injections may be at either outer or temporal end 
of the forehead, gradually being brought nearer to the median 
line until the contour of the whole forehead has been raised by 
subsequent injections. 

UNILATERAL DEFICIENCY 

This defect may be traumatic — the result of direct violence, 
but is more commonly due to a frontal sinus operation. 

In both events it will be found necessary to detach the cica- 
trices that bind the skin down to the injured bone r before a 
prothetic injection may be undertaken. 

In some cases where the cause of the deformity has been 
moderate and the scar is linear and of long standing the injec- 
tion may be undertaken without subcutaneous dissection. 

Several injections are necessary, as the tissue about such 
parts is usually much thickened, apart from the firmness added 
by the scar tissue. 

A short stout needle should be employed, the puncture be- 
ing preferably made under ethyl chloride anesthesia, as the pres- 
sure necessary to raise the tissue causes considerable pain. 

To further facilitate the injection the operator should raise 
the skin with the needle introduced subcutaneously. 

Only one injection of small amount (10-15 drops) should be 
done at a sitting. The injected mass, unless too easily intro- 
duced and thus forming a tumefaction, need not be moulded 
out, since the pressure of the skin overlying it will accomplish 
it more satisfactorily, while the pressure required in moulding 



HYDROCARBON PROTHESES 85 

tends only to press out more or less of the mass, thus lessening 
the benefit of the operation. 

A second sitting must be undertaken in not less than one 
week, or even later, if a subcutaneous dissection has been done. 

The secondary treatment should be followed as heretofore 
described. The reaction, for even a small injection in these 
cases, is usually considerable. 

INTERCILIARY FURROW 

This deformity is usually spoken of as a frown. It may be 
said to be congenital, when it appears in early life but is com- 
monly acquired through the habit of frowning. 

The furrow may be a simple linear one or made up of a num- 
ber of furrows. The author has been called upon to correct 
one made up of six distinct furrows. 

The furrows or creases radiate upward and outward, cone- 
like from a point beginning at the root of the nose. 

In the correction of this common deformity the operator is 
tempted to overdo the fault by hyperinjection. A single furrow 
is readily corrected by a few drops of the injection which should 
be neatly smoothed out. A little of the mass at this part of the 
face seems to accomplish considerable, in fact the part seems 
overcorrected for some time after a judicious and carefully done 
operation, which is undoubtedly due to the active reaction that 
follows such cosmetic procedure owing to the close proximity 
of the frontal veins and those of the venous arch at the root of 
the nose which undergo more or less phlebitis of a mild type ; 
the resultant oedema depending upon the pressure caused by 
the mass on these vessels. The intimate relation and anasto- 



86 HYDROCARBON PROTHESES 

moses of the latter is clearly shown in the carefully prepared 
dissection represented in the frontispiece. 

In injecting, the needle should be introduced at a point di- 
rectly at the root of the furrow or furrows, that is at the junc- 
tion of the forehead with the nose. 

A needle one inch long should be used, taking care not to 
puncture any of the veins which are found to be very differ- 
ently placed in various patients. If blood flows from the needle 
puncture, no injection should be made at that point but another 
be chosen which does not give such result, preferably at a later 
sitting. 

The needle should be introduced well upward under the skin 
so that its point corresponds to the point of greatest depression. 

The injection should be made slowly and continued until a 
tumor, judged to be sufficient to overcome the major deformity 
when moulded out has been formed. 

This knowledge can only be gained by experience and the 
operator must be cautioned to underinject rather than cause 
undue prominence of that part of the face. 

If, however, his judgment has not been accurate enough, the 
operator can immediately thereafter squeeze out enough of the 
filling to give him the desired correction. 

If more than a single furrow is to be corrected, he may in- 
ject the two center ones, leaving the outer for later operation. 

In multiple furrows the injections must be made in cone-like 
form, to give a normal contour to the forehead. The apex of 
such cone corresponding to a point at the root of the nose, and 
the base to an arc with its greatest convexity near the median 
hair line of the scalp, depending upon the length of the furrows. 

The injections in such cases should be made at least three 



HYDROCARBON PROTHESES 87 

days apart, two being made at each sitting, after the central or 
two inner depressions have been raised by the first operations. 
These later injections should be made to relieve the furrows ly- 
ing next to the median, gradually working out to each slant side 
of the cone until the contour of the middle forehead has been 
made normal. 

Never superimpose an injection about the median line until 
the major defect in general has been overcome, and only then 
when the first injections have become settled and organized, as 
such untimely disturbance is liable to set up considerable re- 
action, with enough induration and resultant new connective 
tissue formation, to cause a decided lumpy or protuberant ap- 
pearance of the part. 

The mixtures of low melting points should be preferred to 
the harder variety in frown corrections. They lend themselves 
to better moulding and seem to undergo organization with less 
pathological change than those of the latter class. 

When the injections must be made over the inner third or 
half of the eyebrows, as is often the case, they should be made 
well above the hair line and moulded out in an upward direction, 
to avoid the dropping down of the mass into the upper lids or to 
prevent the resultant displacing connective tissue from involving 
them. 

If the upper lids do become involved, as shown by fullness, 
hardness and partial ptosis, the connective tissue causing the 
same must be carefully cut out from the lid by a transverse 
semicircular incision made in the upper lid along the line of its 
backward fold or hinge. If need be, an elliptical strip of the 
skin of the lid may be removed at the same time to give better 
scope to the extirpation under consideration. 



88 HYDROCARBON PROTHESES 

The author has recently corrected two such cases where a 
surgeon had hyperinjected the entire forehead with a combina- 
tion of oils at one or two sittings. The resultant involvement 
and later discoloration of the lids at the end of a year's time, 
might have been expected. 

Such wounds, when neatly sutured with No. I twisted silk, 
leave surprisingly little scars, in fact the cicatrices are rarely 
ever detected a few days after healing has been established. 

The treatment post-injectio, for all furrow protheses, should 
be as already laid down. 

Apart from general surgical cleanliness and an antiseptic 
powder, the blepharoplastic operation mentioned required no 
special attention. The sutures may be removed in forty-eight 
hours. 

TEMPORAL MUSCULAR DEFICIENCY 

Unilateral and Bilateral 

This facial defect while possibly unilateral as in hemiatrophy 
is generally met with in the bilateral form due to either he- 
reditary causes or a lack of nourishment of the parts, the latter 
usually involving the greater part of the face. Chronic diseases 
and the cachexia dependent upon disease may be the origin, 
in which the deformity is rarely ever overcome entirely by in- 
ternal treatment and massage of the parts ; if anything, massage 
tends to elongate the skin about the temples causing a worse 
disfigurement in the form of numerous fine furrows. 

The correction of the defect under consideration may be 
readily overcome by repeated and careful injections of a hydro- 
carbon of low melting point. 



HYDROCARBON PROTHESES 89 

The author prefers the use of sterilized vaseline injected in 
its cold state. The use of paraffine of high melting points or 
its compounds is not advisable, and if employed leaves the 
temples uneven or lumpy, due to the unequal organization or 
new tissue formation caused thereby, at the same time causing 
sagging of the skin of the adjacent parts, particularly, the upper 
eyelids owing to the added weight of the new tissue growth 
occasioned by such preparations. 

Contrary to general expectation this part of the face is readily 
injected and corrected. 

The skin should be pinched up with the thumb and fore- 
finger of the left hand and the needle introduced with the right 
hand in such way as to exclude the puncturing of blood vessels. 

To assure the operator against such difficulty the needle may 
be withdrawn after insertion and if blood does not trickle from 
the wound it may be reintroduced without pain to the patient 
and the injection begun. 

It is not advisable to correct the defect at one sitting. One- 
third or one-half of the depressed area may be overcome 
by one injection. The resultant tumefaction must then be 
thoroughly moulded out, until little seems to have been accom- 
plished by the injection. 

The operator trusts in these particular cases more to the 
development of new connective tissue than in any other part 
of the face, except perhaps in the correction of an interciliary 
furrow. It is surprising how much is attained by the most con- 
servative injections in and about the temples. 

The moulding of the injected mass must be done in a supe- 
rio-posterior direction to avoid forcing it into the upper eyelids 
resulting in the same over-development previously referred to. 



9 o HYDROCARBON PROTHESES 

Both temples should be injected as advised at one sitting. 
The use of the ethyl chloride spray makes the operation less 
fearful to the patient. 

Subsequent injections should not be done earlier than three 
weeks or until any discoloration of the skin of the parts has dis- 
appeared. The latter is not an unusual occurence and is un- 
doubtedly due to the pressure of the injected mass upon the 
numerous blood vessels found there. 

The post operative treatment should be followed as here- 
tofore advocated. 

DEFORMITIES OF THE NOSE 

The use of hydrocarbon protheses for the correction of nasal 
deformities has revolutionized, to a great extent, the rhinoplasty 
of many centuries. Through their employment many unsatis- 
factory cutting operations have been entirely displaced and it is 
quite right to hold, that the introduction of other subcutaneous 
protheses and like apparatuses of amber, celluloid, catchouc, 
silver, gold, aluminium, ivory or other nature have been sup- 
planted by this method of operation, when these were needed 
to correct a partial deformity of the nose. 

When a total rhinoplasty has to be undertaken the paraffin e 
group of protheses of course cannot be resorted to, owing to a 
lack of the necessary retentative walls of tissue, except per- 
haps in such cases where the so-called ' double flap, or French 
method, is employed and there only after the parts have be- 
come thoroughly organized. 

A somewhat complete tabulation of nasal defects has been 
given heretofore which gives an excellent idea of the extensive 
use these hydrocarbon injections may be put to. 






HYDROCARBON PR'OTHESES 91 

Such nasal deformities as are amenable to this method of 
correction may be due to either congenital causes, lack of de- 
velopment, direct violence, ulcerative changes following catarrh, 
syphilis and tubercular disease. In some cases, however, the 
defects are purely of a cosmetic nature, and not considered as 
abnormalities except by the critical eye of the patient. This is 
true particularly with lobular and supra-alar deficiencies, as well 
as a slight lack of contour about the anterior line. 

In some instances, the defect may be an acquired one, as in 
the lateral deviation known as handkerchief bend. 

A specific and somewhat elaborate classification has been given 
to the more important and distinctive deformities of the nose, 
principally to facilitate the proper citation and recording of 
cases. 

It may be readily understood that each one of these classifi- 
cations may be further subdivided, but such subdivision can be 
only of the degree or extent of the deformity and must be left 
to the individual operator and his thoroughness of observation 
and nicety of recording. 

The author prefers making a plaster cast of the entire nose 
which is to be corrected and a second cast after the operation 
has been completed, or at the time of his discharge. A record 
sheet, or a direct photograph can be made before and after op- 
eration for the same purpose which is not so desirable, how- 
ever, because it has been found quite impossible to procure 
the desired accurate pictures of a nasal deformity, the photog- 
rapher not being given to bringing out imperfections as the 
surgeon wishes them, even under the most explicit instructions, 
unless the surgeon accompanies the patient to the studio to 
supervise the posing. This requires a waste of valuable time ; 



92 HYDROCARBON PROTHESES 

not to speak of the expense of making pictures of a pathologi- 
cal nature. The better way would be to have an apparatus in 
the operating room. The surgeon can then pose his patient 
against a screen background in the position and to the size of 
picture he may desire. Plate cameras and time exposures are 
best for this purpose. For recording and half tone reproduc- 
tion silver prints are found best. 

For all deformities of the anterior nasal line a hydrocarbon 
compound of the higher melting points should be used. This 
should be injected in the cold form. The mixture given on 
page 39, with perhaps an added half dram or dram of paraffine 
has been found excellent. The addition of paraffine being made 
to assure a suitable fineness of coutour and width. The softer 
mixtures are more liable to cause a lack of contour and a conse- 
quent widening of the part injected, even after moulding, be- 
cause of the contractility of the skin overlying the injected mass 
which tends to flatten it out giving the nose a less artistic and 
delicate appearance. 

Furthermore, a soft mixture will be found to be inefficient in 
overcoming the tension of the skin in most cases, especially 
those about the middle third of the nose. 

In some cases of lateral deformity, and where otherwise men- 
tioned, it is advisable to use only a mixture of the lower melting 
points as in the case in the correction of interciliary furrows and 
temporal muscular deficiency. 

Superior Third Deficiency. — The degree of depression about 
the superior third or root of the nose varies considerably. The 
most extensive form may be commonly found in the negro nose 
where there is almost an absence of a rise in that part of the 
nasal bones. Such noses are also found in the Chinese and Jap- 



f 




Q 




X 



< 



HYDROCARBON PROTHESES 93 

anese. The condition ofttimes may be associated with epican- 
thus. 

Epicanthus, formerly corrected by an elliptical excision done 
anteriorly, can be entirely overcome by the subcutaneous injec- 
tion method, thus not only avoiding the resultant linear cicatrix 
but building up the depressed nose to its normal contour. 

The skin overlying most of the defects of the superior third 
is usually found to be loose, hence injection is readily accom- 
plished. 

The needle should be introduced laterally and anterior to the 
angular vessels to prevent their occlusion and injection. The 
point of selection is made at about the middle of the deformity. 
The needle is introduced until its point lies in the center of the 
depression, or at the median line from the anterior view. 

The mass is injected slowly as the skin of the nose is pinched 
up between the forefinger and thumb of an assistant. 

The part is injected until a tumefaction, equal in body to the 
extent of the deformity, is attained. 

The needle is allowed to remain in place for a moment, to 
permit of a stoppage of the thread-like mass, usually following 
the pressure applied to the piston, after the operator has stopped 
turning the screw. This will prevent the mass from following 
into the channel made by the needle, or the backing up of the 
mass, as it were. Should this occur the paraffine mixture should 
be squeezed from the skin opening to prevent the formation of 
an inter-cutaneous encystment. 

Immediately the needle is withdrawn the operator places a 
finger tip over the opening and proceeds with the thumb and 
forefinger of the right hand to mould the mass into the desired 
shape. 



94 HYDROCARBON PROTHESES 

The post-operative treatment should be as previously given 
and is the same with all injections about the nose, so that it will 
not be referred to again under this heading. 

While a fairly large defect can be corrected at one sitting, it 
is advisable to rather reinject one or two weeks later to secure 
the exact shape. 

It is to be impressed upon the operator that there is al- 
ways a slight broadening of this part of the nose following the 
development of the connective tissue which takes the place of 
the injected mass, hence the injection should not be overcrowded 
nor the parts overcorrected. 

The mass should be moulded out as narrow as possible and 
be pinched between the fingers by the patient two or three 
times a day after the reaction has subsided, which is usually 
about the third day. This procedure will keep the mass from 
being flattened during the time tissue replacement takes 
place. 

Middle Third Deficiency. — This defect is commonly seen in 
football players and pugilists as the result of a breaking of the 
inferior extremities of the nasal bones and the displacement of 
the articulating cartilages, although the defect is often seen as 
a result of an injury to the nose early in life, causing a lack of 
development in the superior or articulating extremities of the 
cartilages. Nondevelopment from catarrh, syphilis and in- 
tranasal disease are other causes. This type of deformity is 
generally designated as the saddle nose. 

In the latter cases the skin is usually bound down to the 
cartilaginous structure by cicatricial bands and needs to be lib- 
erated. This is accomplished subcutaneously with a fine teno- 
tome introduced laterally. 




c 
'o 

Q 



H 




HYDROCARBON PROTHESES 95 

To assure the operator ot a thorough dissection he may inject 
the site with sterile water through the opening made with the 
knife, squeezing it out before injecting the nose. 

If the skin has had to be freed by surgical means the mass 
injected should be sufficient to overcome the defect almost en- 
tirely, to prevent the reformation of the bands of connective 
tissue which have been severed. Their re-establishment would 
mean an unequal development of the new connective tissue 
springing up from the injected mass thus defeating the object 
of the operation. 

If no dissection has been done the defect should be corrected 
about two-thirds and added to by a subsequent injection. 

The mass in either case should be well moulded out, espe- 
cially at both sides to keep the nose as narrow as possible. 
There will be more or less widening ultimately following the 
organization of the mass. 

It is not uncommon to find a dividing wall of subcutaneous 
tissue about the articulation of the nasal bones and cartilages 
as evidenced by a rising up or down of the injected mass above 
or below this line. If this be found, rather than break down 
this wall with the injection it is deemed advisable to inject each 
chamber separately and mould the two masses after injection 
as in the ordinary type of cases. 

Inferior Third Deficiency. — This deformity of the nose is due 
purely to a lack of development or a luxation of the cartilage 
of the septum and the upper lateral cartilages. The point or 
lobule of the nose is usually tilted upward and the subseptum 
curved upward at its middle third. 

The cause of this deformity is usually due to direct violence 
at some time in life, with improper replacement at the time of 



96 HYDROCARBON PROTHESES 

injury. Syphilis and intranasal catarrh, lupus and ulcerative 
diseases are also causes. 

The skin overlying the defect may or may not be closely ad- 
herent, but is in most cases rather thickened and inelastic. It 
is therefore necessary, in most cases, to loosen the skin by sub- 
cutaneous dissection done as already described before the injec- 
tion is made. 

To rebuild such a nasal defect without dissection, except in 
such instances where the skin is quite elastic, is not to be ad- 
vised, since the injected mass would be flattened, more or less, 
antero-posteriorly, giving the nose a broad and ugly appearance 
after the connective tissue formation has been attained. 

It is with cases of this kind that paraffine injections intro- 
duced in the liquid form and of high melting points, are usually 
expelled in a week or ten days, or even later, subsequent to a 
breaking down of the surrounding tissues and the resultant 
abscess. 

The best preparation to employ is the form of paraffine mix- 
ture advocated in the preceding operation used in its cold state 
and injected slowly, after the integument has been rendered 
mobile enough to permit the desirable correction. 

The defect should not be corrected in one sitting for the 
very reason that some widening of the nose may take place 
owing to the contractility of the skin, post-operatio. 

The mass injected should correct the major part of the defect 
and be moulded out carefully, especially from both sides of the 
nose and the patient be instructed to pinch the nose laterally 
several times a day after the reactive inflammation has subsided 
with the object of keeping the nose as narrow as possible. 

After the mass has been thoroughly replaced with connec- 



HYDROCARBON PROTHESES 97 

tive tissue and the anterior line is found to be too depressed, a 
fine line of the mass about the thickness of the needle may be 
injected over it in a vertical direction ; the point of a fairly 
large needle being introduced just above the anterior aspect of 
the lobule and thrust upward to the superior border of the now 
existing deformity and be slowly withdrawn as the mass is in- 
jected. 

This will leave a rounded cylindrical like mass along the an- 
terior nasal line, which must not be moulded at all, except to 
soften or shade off the superior and inferior extremities. 

The author advocates making two such injections, at the same 
sitting when the deformity has persisted. These injections are 
made parallel to each other with a distance of about one-eighth 
inch between them. 

The subseptal deficiency will also have to be corrected. This 
will be referred to later under its separate division. 

The reaction in cases of this type is usually more severe than 
in those just mentioned. There may be considerable swelling 
and discoloration, but by following the methods of treatment 
laid down heretofore the symptoms usually subside in two or 
three days. 

Superior Half Deficiency. — In this type of deformity there is 
found a nondevelopment of the bridge of the nose, while the 
greater part of the cartilage of the septum and the lower lateral 
cartilages seem to be quite normal in contour. The nose has a 
dished appearance, with an undue prominence of the nasal base 
or lower half. 

Various causes may be given to this condition, but heredity 
is responsible in a great majority of the cases. 

The deformity in the type under consideration rarely takes 



98 HYDROCARBON PROTHESES 

in an accurate half of the nose, there being an involvement more 
or less of the lower anterior half, yet it is sufficiently distinctive 
to give it specific classification. 

For the correction of the defect in such cases the injection is 
made laterally, the same mass being employed as in the preced- 
ing cases. 

In this type of case the mass injected should quite correct 
the defect and be moulded with great care to a desired contour, 
keeping in mind always the condition and elasticity of the skin 
overlying it. 

An inflexible skin should be rendered mobile by digital mas- 
sage, practiced for a few days prior to operation, or in tense 
conditions be loosened by subcutaneous dissection. 

The great fault in injecting so large a quantity as is neces- 
sary in these cases, is to make the nose too wide from the very 
beginning, which added to the widening following the replace- 
ment by new tissue, makes the shape of the nose unsatisfac- 
tory. 

For this reason it will be found of some benefit to apply an 
anterior nasal splint of aluminium, covered interiorly with a fold 
of white flannel or gauze and pressed into such shape, that when 
applied to the nose it will keep the latter pinched up laterally to 
the desired width. This splint will hardly ever be borne by a 
patient and causes great discomfort until after the post-opera- 
tive reaction has subsided. It may then be bandaged or held 
in place by strips of Z. O. Adhesive plaster for an hour or two 
in the day and during the entire night. 

After the first few days' wearing the patient soon becomes ac- 
customed to the splint. It should be worn as mentioned for 
about three weeks, when the patient may be permitted to pinch 



HYDROCARBON PROTHESES 99 

the nose laterally with his fingers two or three times a week or 
more. 

The secondary injection may be made in the ordinary way or 
as advocated by the author in the manner described in correct- 
ing defects of the inferior third of the nose. 

Inferior Half Deficiency. — In this type of deformity the 
greater point of nondevelopment or deficiency is found at the 
upper extremity of the cartilage of the septum, below its artic- 
ulation with the inferior border of the nasal bones, and involving 
to a greater extent the area over the upper lateral cartilages. 

This deformity, due to whatever cause, rarely affects the base 
or inferior part of the nose owing undoubtedly to the greater 
protection and stability offered by the lower lateral and sesa- 
moid cartilages and the dense cellular tissue making up the 
alae. Except in such cases where violence of an extreme na- 
ture has been exerted in early life, or where ulcerative disease 
has broken down most of the cartilage of the septum, the point 
of the nose is usually normal in size and shape. In the latter 
cases there is an upper tilt of the lobule and a shortening of 
the calumna upon itself with a convexity in an upward direc- 
tion. 

The cause of this type of deformity is usually a direct blow 
upon the point of the nose, syphilitic ulceration internally, ca- 
tarrh or other ulcerative disease. 

When due to violence the point of the nose may or may not 
present a normal appearance, there may be a normal base tilted 
upward (retrousse or snout nose) or a dropping forward and 
downward (hook or beak nose). 

The shape of the nasal base depends much upon the time 
of life the injury was received, that is before or long after pu- 



ioo HYDROCARBON PROTHESES 

berty, also upon the extent of injury inflicted and where ap- 
plied. 

From injuries received early in life we may look to a lack of 
development in the cartilage of the septum alone, or associated 
with deficiency in one or both lateral cartilages. 

The deformity is usually symmetrical, but where the nasal 
bones have been injured as well, particularly where one bone is 
injured more than its fellow, there is a possibility of the disfig- 
urement being unilateral. This is rarely the case except when 
due to punctured wounds ; generally in such cases the anterior 
nasal line assumes a twisted form. 

Some operators have included noses of undue lobular prom- 
inence (a la Cyrano de Bergerac) under this type of deformity 
and while it is to be admitted such a nose might be built up by 
subcutaneous prothesis the result is anything but harmonious 
or normal. Such a nose should be reduced by cutting opera- 
tions instead of being added to. The seeming depression above 
the lobule is only comparative to the overdeveloped form of the 
lobule. The face values of every patient should be studied and 
the surgeon should never attempt to break up the harmony of 
facial form by simplifying an operation and rendering the pa- 
tient's appearance even more ridiculous than before his attempt 
to correct a fault. 

The correction of the deficiencies of the lower half of the 
nose is associated with difficulties in various directions. Either 
the skin over the defect is too dense to render injection an easy 
matter, or the nose is so broadened horizontally from the orig- 
inal injury that the injection, no matter how artistically done, 
leaves the nose bulky and ugly in appearance. 

When the nasal processes of the superior maxillary bones 



HYDROCARBON PROTHESES 101 

have not been widened unduly by an injury and the skin is dense, 
simple subcutaneous dissection before injection will overcome 
the difficulty easily enough. 

In that case the needle is inserted laterally in a line with the 
maximum depth of the depression and the point shoved up to 
the median line anteriorly. 

Enough of the cold mixture of paraffine and vaseline, as 
heretofore advised, is injected to reduce the deformity nearly 
to the normal. 

The mass is moulded to give the nose as near a normal con- 
tour as possible always keeping in mind the later broadening of 
the nose when the new connective tissue has taken the place 
of the injected mass. A later injection made as advised here- 
tofore will restore the anterior line to better form. 

If the nasal processes of the superior maxillary bones have 
been thrown outward considerably a surgical operation is neces- 
sary to reduce them. 

No injection should be made until the wounds from such 
operation are thoroughly healed and contracted. 

In all cases of this type the skin will be found to be rather 
dense and likely to be tied down by past inflammations to the 
anterior aspects of the lower lateral cartilages at their juncture 
with the upper lateral cartilages. If the adhesions are not too 
dense the harder form of the cold mixture should be used. This 
will not only permit of raising the skin more readily than with 
a softer kind of mixture, but will be more likely to retain its 
form under the contractile pressure brought to bear down upon 
it. 

When the skin is closely adherent it should be loosened sub- 
cutaneously as already advised. The injection may be done at 



io2 HYDROCARBON PROTHESES 

the same sitting and be of greater quantity than in the cases 
where this had not been done, for the reasons mentioned. 

Pressure splints and manual compression should be employed 
as in the preceding deformity. 

The reaction following the first injection is likely to be severe. 
Cold applications as previously referred to are indicated and 
should be continued for at least two days. 

Care should be taken not to inject into the lateral vessels 
which usually lie on a line with the juncture between the lateral 
and lower lateral cartilages. If this should happen, the point of 
the nose at once assumes a bluish hue, there is more or less 
pain felt at once, with considerable swelling a few hours after 
the injection. Later, every symptom of gangrene of the lobule 
is liable to be noticed, yet with faithful attention to furthering 
the circulation of the parts by either cold or hot applications, 
the active inflammatory symptons usually subside in ten to four- 
teen days, leaving the patient with a whole nose, more or less 
colored at the lobule according to the state of the circulation 
and the exposure of the parts to the various temperatures. This 
may be overcome in time, yet it may persist for years, depend- 
ing entirely upon the ability of the anastomosing vessels to 
overcome the artificial thrombus or occlusion offered by the 
mass injected. 

That a reaction quite similar in character, but of milder de- 
gree, is likely to be seen when one of these vessels have not 
been injected, can be readily understood when we consider that 
a hard and somewhat ungiving mass is made to overlie the ves- 
sels themselves. The symptoms just described in such case are 
apt to be noted much later, even several hours after the injec- 
tion, because the swelling has then begun to add its pressure to 




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HYDROCARBON PROTHESES 103 

that of the mass in obstructing the flow of blood to the lobule. 
Such condition may be termed pressure occlusion in contradis- 
tinction to thrombotic obstruction. 

These symptons usually subside in a day or two, or with the 
swelling caused by the reaction. 

If the symptoms appear at once after the injection, it is best 
to force out as much of the injected mass as is possible through 
the needle hole through which it has been introduced. 

The author was called to attend a case several hours after 
the operator had injected a nose. The acute symptoms pointed 
to a direct occlusion of the vessels, yet the surgeon who had 
performed the operation assured me he had not injected until 
he found that blood did not flow from the needle after its inser- 
tion. To relieve the patient of immediate fright and some pain, 
a dull pointed needle of larger calibre than the one used in 
operation, was pushed through the needle wound previously 
made, taking the place of a canula, and a greater part of the 
injected mass was squeezed out. Ice cloth applications were 
followed through the night and the nose recovered in three days 
without showing the discoloration of the skin usually observed 
following such cases. The nose was never injected again, on 
account of the dread of the patient, but peculiarly the anterior 
line showed almost a normal contour after four weeks had 
elapsed. This only goes to prove that very much less of the 
mass to be injected is required than is commonly supposed by 
operators. 

Total Anterior Deficiency. — In this condition there is a 
scooped-out or general curved-in appearance of the entire ante- 
rior nasal line. The lobule of the* nose is usually normal in 
size. 



104 HYDROCARBON PROTHESES 

This defect should be corrected by two injections of the par- 
affine compound previously referred to. The points of injection 
should be lateral and anterior to the angular vessel on the side 
of the nose preferred by the operator. One about the center or 
major curvature and the other about the inferior third. 

Care should be taken to mould the injected mass as narrow- 
as possible, or as much as the skin will permit. If the latter 
is bound down it should be mobilized by subcutaneous dis- 
section or levation. A subsequent injection should not be un- 
dertaken until the entire mass has become settled or fairly or- 
ganized, which is about the end of three weeks. 

The mass should be injected well up to the root of the nose 
to give it the appearance of the normal bridge. If this is found 
impossible owing to a dividing skin attachment, a third needle 
puncture should be made at a point on a level with the inter- 
nal canthus. 

Care must be exercised to keep the mass from creeping into 
the loose tissue about the internal canthi by having an assistant 
press the sides of the nose at that point with the thumb and 
forefinger. 

This undesirable condition is much more liable to occur when 
a hot liquid parafnne is employed, since the operator can observe 
quite accurately the extent and direction taken by the mass in- 
jected when the cold product is used. 

Some authorities have injected noses of this type from the 
point of the nose, but it will be found that the position of the 
puncture at this point allows a considerable portion of the mass 
to work out during moulding and also to permit of the readier 
oozing out of the mass during the pressure exerted by what re- 
active inflammation follows the operation. This is accounted 




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HYDROCARBON PROTHESES 105 

for by the fact that the needle creates a tube like canal in the 
tightly bound down tissue overlying the lower lateral cartilages, 
whereas in the lateral punctures the short canal is easily dis- 
placed by the swelling, thus causing its obliteration and prevent- 
ing the free oozing. 

On the other hand, it will be found to be more difficult to in- 
ject from the point of the nose alone and that a very long needle 
has to be used which must be withdrawn as the parts above the 
point are filled. Furthermore, it will be found necessary to 
thrust the point of the needle in different directions to overcome 
vertical attachments of the skin which are more readily lifted 
up than thrust aside by the mass, hence necessitating a greater 
amount of injury to the tissues, not to speak of the possibility 
of injecting transverse blood vessels higher up in the nose of 
which the operator would not be aware at the time ; showing 
only in the resultant phlebitis and unexpected reactive symptoms, 
associated with a discoloration more or less lasting according to 
the extent of obliteration of the vessels. 

The post-operative treatment should be as heretofore ad- 
vised. 

Lateral Insufficiency — Unilateral and Bilateral. — Depressions 
about the sides of the nose are usually due to hereditary causes, 
when they are likely to be bilateral, yet intranasal ulcerations 
may cause a falling-in, as it were, of either one or both nasal 
walls, involving in such instances the entire side or part of it. 
In the partial cases the depression may be in any of the division 
of thirds used by the author, that is, it may lie laterally over 
the region of the nasal bone and such of the nasal process of 
the superior maxillary bone as goes to make up that part of the 
nose, or in the middle third below the bone structure and above 



106 HYDROCARBON PROTHESES 

the superior limitation of the lower lateral cartilages, or within 
the lower third over the inferior border of the cellular tissue 
making up the nasal rim. 

Traumatism may be found to be the cause of such depressions, 
especially in the middle third, after fracture or luxation of the 
nose. In such cases the defect is usually unilateral or at the 
seat of the former injury, a convexity usually being exhibited 
on the opposite side. 

Since the skin is rather firmly adherent at the sides of the nose, 
except in the major part of the superior third, it will be found 
best to raise the skin of such defect into normal contour by a 
series of very small injections instead of following the method 
heretofore advised in connection with tense or adherent areas 
of skin, for the reason that such dissection would render the 
skin too mobile over an area usually beyond the defect itself and 
inviting the surgeon to an annoying hyperinjection which ren- 
ders the part more unsightly than prior to the operation. This 
is true in most cases unless the depression is of traumatic origin 
and beyond the size of deformity usually corrected. 

The author advocates the employment of a hypodermic needle 
attached to the syringe in place of the regular needle and that 
the injection be of sterile white vaseline without additions of 
any kind. 

Such injections may be made very readily, one or more at 
the first sitting, being introduced below the deepest part of the 
defect. It is surprising how much four or five drops of such an 
injection will accomplish. Furthermore, it is to be remembered 
that the injections about the side of the nose are readily replaced 
by new connective tissue, equal to, if not commonly greater in 
amount than the mass injected, such growth being completed 



HYDROCARBON PROTHESES 107 

in about two months after the time of injection. This may be 
explained by a more or less active perichondritis when the in- 
jection is made over the cartilage, the inflammation, thus set up, 
being of longer duration than where skin and bone or areolar 
tissue are involved. Any subsequent injection should not be 
undertaken until at the end of two weeks or more for the rea- 
sons above stated. 

The injected mass at all times should be introduced under 
normal pressure, never to the extent of rendering the skin above 
it white in color. The mass should also be moulded out with 
the tip of the finger or the rounded, dull handle end of a scalpel. 
If necessary, the small finger may be introduced into the nos- 
tril to facilitate this moulding. Should the reactive inflamma- 
tion be severe such remedial agents as have been referred to 
should be used to reduce it. 

Phlebitis following injections at the side of the nose is due 
entirely to the injection of a blood vessel and must be avoided. 
When a fine needle is used there is less likelihood of free bleed- 
ing from an injured vessel, therefore a thorough knowledge of 
the usual position of the vessels about the sides of the nose is 
absolutely essential. Bleeding of greater extent than that which 
would follow the thrust of the needle through the skin should 
put the surgeon on his guard. Experience is the better teacher 
and conservatism in these, ofttimes delicate, subcutaneous op- 
erations will save the surgeon much annoyance and eventually 
the need of having the patient submit to a cutting operation to 
reduce an overcorrected area. 

Should a hyperplasia of connective tissue result from such an 
operation, a small linear incision, under 4.% eucaine anesthesia, 
should be made directly over the greatest prominence, through 



108 HYDROCARBON PROTHESES 

which the offending mass can be removed by the aid of a small 
hooked knife or a fine pair of curved scissors. 

The mass should be removed beyond the plane of the skin, 
in fact it should be rather removed in cone-like form, apex in- 
ward, and the peripheral attachment completely obliterated, in 
order to obtain the desired result, as it is not unusual to have 
the prominence reappear after imperfect extirpation and im- 
proper dissection. 

Moist pressure dressings may be applied over the small wound 
thus made, for several days, or until the inflammation following 
the operation has subsided. Suturing such a wound is hardly 
necessary, but if the incision be over one-fourth of. an inch long* 
two fine silk sutures, deeply placed, may be utilized, their ten- 
sion adding to the compression needed to bring the mobilized 
skin into position in reference to the base of the wound. 

The author has used contractile collodion in place of compress 
dressings with very good result. This should be renewed 
within forty-eight hours. 

After eight or ten days silk isinglass adhesive plaster is ap- 
plied over the wound until it falls off. 

Lobular Insufficiency. — This defect of the nose is usually of 
hereditary origin although it may be occasioned by the retrac- 
tion of the inferior half of the organ in tubercular or syphilitic 
ulceration in which the lobule falls inward and upward by the 
loss of the retaining cartilages. 

Owing to the close adhesion of the skin to the lower lateral 
cartilages and the cellular tissue about the rim of the alae it is 
found difficult to restore the contour or elongate the organ at 
that site by subcutaneous injection. 

Even after thorough mobilization of the integument the sub- 



HYDROCARBON PROTHESES 109 

sequent injected mass is liable to be thrown off by an overac- 
tive inflammatory reaction, due undoubtedly to the adhesions 
formed between the divided surfaces from the periphery inward 
which has a tendency to crowd the injected mass forward and 
downward before a new connective tissue has had time to be 
formed, causing a breaking down of the skin at some point over- 
lying the mass and allowing it to escape. 

The author has attempted to replace the injection by small 
solid paraffme plates introduced through a small lateral incision 
made for the subcutaneous dissection, and while the wound 
healed readily enough and the nose appeared normal the plates 
were in every case thrown off by a later inflammatory process 
before the end of the third week. 

The author then attempted to replace the solid plates with 
granular paraffme, gently packing the latter into the wound un- 
til the desired elevation had been obtained with the idea that 
such mass would accommodate itself much better under the 
pressure caused by reactive inflammation, but even this pro- 
cedure proved unsuccessful. 

The best results are obtained with sterilized white vaseline 
injections when there is considerable mobility of the skin. A 
single needle opening should be made, preferably about the 
center of the side of the lobule, or slightly anterior to this point, 
carrying the point of the needle forward to the anterior medium 
line and a little above the actual point of the nose. 

The injection should be made slowly, closely watching the 
size of the elevation caused by the mass and the state of the 
circulation about the entire lobule. 

Usually ten drops of the mass suffice to give the desired re- 
sult. The mass may be moulded out if found desirable, but if 



no HYDROCARBON PROTHESES 

the skin appears normal after the operation and the tumefac- 
tion thus made does not make the nose look grotesque it may be 
allowed to remain as injected, depending upon the subsequent 
reactive pressure to force it into shape. In this way a greater 
part of the mass is retained at the wanted site and is not 
crowded to the sides of the lobule by the customary post-opera- 
tive moulding. 

Even with this method great care must be exercised in not 
injecting too much at each sitting. A failure is sure to result 
in hyperinjection about the lobule. When it be remembered 
that only a very small quantity of the mass will make a decided 
difference the surgeon and patient should be satisfied with the 
slightest gain. 

If, however, the mass be retained and further elongation of 
the lobule is desired a subsequent injection can be undertaken, 
but not until a full month after the primary operation. 

Here, as with lateral nasal injections, there seems to be an 
overproduction of new connective tissue following such an in- 
jection ; a decided factor in eventually pleasing .the patient. 

It is needless to say that the operator must avoid injecting 
one of the blood vessels of the lobule as this will cause consid- 
erable inflammation from which the lobule does not recover 
readily, owing to the dense tissue the surgeon has to deal with, 
leaving the tip of the nose discolored and bluish for some time 
after the operation. 

If the injected mass causes an immediate venous stasis of the 
lobule hot applications should be applied at once, or as soon as 
the operator discovers that the proper massage and pressure to 
remove the offending mass does not improve the circulation. 

The author advocates the judicious use of antiphlogistine 



HYDROCARBON PROTHESES in 

faithfully applied hot every six hours and continued until the 
acute inflammatory symptoms subside, when the surgeon may 
resort to ice cloths or cold pack until the danger of pressure 
and resultant gangrene have subsided. 

Despite the very grave symptoms associated with such in- 
flammation the operator may assure the patient against perma- 
nent disfigurement, although the three or four weeks' duration 
of treatment, usually required in such cases, is an ordeal the 
cosmetic surgeon and the patient is not liable to forget. 

If the injected mass causing this state of affairs has been of 
liquid parafrlne, the better method to pursue is to make several 
small incisions into the site of the injections and remove the 
little masses of solid parafrlne as far as possible with the view 
of relieving the pressure or encroachment, at the same time al- 
leviating the pain and stasis by the resultant depletion. Moist, 
hot applications should follow this procedure. The small wounds 
made in the skin will heal without suture leaving hardly any 
perceptible scar. 

The author, however, advises against any mixture or liquid 
parafrlne injections about the lobule, never having seen a satis- 
factory result when either had been employed. 

The post-operative treatment in uncomplicated cases may be 
of aristol and adhesive isinglass plaster or collodion. 

Interlobular Deficiency. — This condition is hereditary in the 
great majority of cases. The defect, while quite disfiguring 
giving the appearance of a cleft nasal point, is easily corrected 
by the subcutaneous injection method. 

Paraffines of high melting points should, however, never be 
employed for this purpose for diverse reasons : — first, the hard- 
ening of the mass after cooling causes too much pressure upon 



ii2 HYDROCARBON PROTHESES 

the small blood vessels at the point of the nose and results in 
more or less permanent discoloration of the tip ; second, by 
reason of the pressure of a hard mass, at the end of the nose, 
considerable inflammation results which usually terminates in 
the evacuation of the entire mass and consequent cicatrization ; 
third, by virtue of the greater irritating qualities of paraffine a 
greater amount of new connective tissue than necessary is 
thrown out causing a general and hyperplastic rounding of the 
entire tip of the nose that requires surgical interference to over- 
come. In the illustration shown the patient's nose was injected 
along the entire anterior line and the lobule with paraffine liqui- 
fied under heat. A marked post-operative inflammation re- 
sulted with permanent redness of the entire organ and several 
decisive capillaries showing about the sides and tip of the nose. 
This was followed in about six weeks by a progressive hyper- 
plasia which left the nose about three times its natural size, and 
the lobule a hard ball-like knob of high red color. Several 
cosmetic operations were required to make the nose appear any- 
where near normal, while the electrolytic needling process was 
resorted to for a number of sittings to destroy the acute redness 
and the individual vessels showing. 

While a great many workers with paraffine deny any benefi- 
cial results from the employment of sterile white vaseline for 
subcutaneous injections the author claims that in this particular 
class of deformity it is almost exclusively required. 

The vaseline in cold state should be injected directly under 
the skin overlying the deepest point of the cleft and be slowly 
continued until the lobule assumes its normal contour. The 
puncture may be made below the point of the nose. 

One such injection usually suffices to correct the fault. The 




Untoward Effect of Paraffine Injection 
About Lobule and Anterior Nasal Line 

Scar lines on Nose Indicate the Various Attempts 
Made to Reduce the Resultant Hyperplasia 



HYDROCARBON PROTHESES 113 

reactive symptoms are not severe if proper technic has been ap- 
plied and cold compresses usually relieve it within twenty-four 
hours. 

Should the skin be adherent about the anterior aspect of the 
lower lateral cartilages it can be forced away with a small, dull, 
round pointed knife resembling an eye spud, the opening for 
which need not necessarily be greater than that made for the 
needle. The latter is inserted through the same opening which 
must be closed over in this event with a drop of contractile col- 
lodion into which aristol is introduced with the pulverflator, 
which not only embodies an antiseptic, but at the same time 
hastens its hardening. 

Alar Deficiency — Unilateral and Bilateral. — The contraction 
about the nasal rims may be due to hereditary causes or the re- 
sult of intra-nasal disease. The defect is usually bilateral involv- 
ing the entire alae or only their lower half or third. 

The fault should be corrected by several injections made along 
the rim of the nasal wing using a fine needle, preferably of the 
hypodermic size. Vaseline only should be used and two or three 
drops, according to the extent of the deformity, be injected into 
the cellular tissue at the point of each needle insertion. 

Three of such punctures may be made along the rim, one be- 
yond the other in each wing. According to the defect the injec- 
tion may be carried higher or lower above the margin of the rim 
by shoving the needle upward and toward the inferior border of 
the lower lateral cartilage. 

The reaction in these cases is very little, rarely necessitating 
other than an antiseptic powder-plaster dressing. Subsequent 
injections should be made if the first do not give the desired 
contour ; but never until the surgeon is satisfied that the result- 



ii 4 HYDROCARBON PROTHESES 

ant new connective tissue thrown out has reached its ultimate 
growth. 

The harder paraffines, especially those injected in the liquified 
state, are not to be tolerated for the reasons given with the pro- 
ceeding method of correction. 

Subseptal Deficiency — Partial and Complete. — It is not un- 
common to find a marked concavity of the subseptum in noses 
that have sunken in by reason of intranasal disease or traumatism. 

This concavity when partial is usually most marked near the 
lobule but in the complete variety the upward curve may be 
greatest near its juncture with the lip. 

Owing to the usual adhesions formed during the inflamma- 
tory period causing the deformity the correction of this defect 
is quite difficult. As a rule the skin of the entire subseptum 
needs to be dissected away from the underlying structure 
before it will permit of correction by the injection method. 

This dissection is advocated and can be readily done from one 
of the nostrils at a point just beyond the union of skin and mu- 
cous membrane. 

The dissection under such method can be made more 
thoroughly than when done exteriorly for the reason that the 
entire field is laid open to a free use of the scalpel leaving no 
visible cicatrix externally. The dissection may be followed by 
the immediate injection of the mixture of paraffine and vaseline 
as already referred to, used cold, or the area is injected with 
normal salt solution until the intranasal wound has healed, 
which usually takes place in about five days. The mucous 
membrane in such instance may be neatly but not too tightly 
sutured with No i silk. If the operator deems it advisable 
he may inject the salt solution again on the third day to pre- 



HYDROCARBON PROTHESES 115 

vent the formation of such adhesions as may interfere with 
the ultimate hydrocarbon injection. This is rarely found nec- 
essary. 

If the post-operative inflammation prove mild, then the adhe- 
sions will not be as tenacious, in which case the surgeon may 
wait until even the seventh or eighth day before injecting the 
paraffine compound to be sure of not forcing the intranasal 
wound apart under the pressure of the mass injected. 

Never should so large a quantity of the mass be injected as 
to cause blanching of the narrow strip of skin. This is sure to 
result in gangrene of some, if not all, of the skin of the sub- 
septum — a result much to be regretted since subsequent cor- 
rection of the deformity increased by the contraction of the 
dermal cicatrix is rendered well-nigh impossible by reason of 
this very tissue. 

Hard paraffine injected in its molten state is never borne in 
this part of the human economy. It is usually thrown off after 
a few days of very painful and highly inflammatory symptoms, 
undoubtedly explained by the fact that the circulation of the 
subseptum is principally dependent upon the delicate branches 
of the two small septal arteries of the superior coronary and a 
hard ungiving mass would readily cause their obliteration. 

DEFORMITIES ABOUT THE MOUTH 

LABIAL DEFICIENCY 

Upper and Lower Lip 

There are a number of causes creating deficiencies about the 
labial orifice. The same causes apply naturally to both lips 
whether the defect be unilateral, bilateral or median. Some of 



n6 HYDROCARBON PROTHESES 

these deformities are more often met with than others, as, for 
instance, a median deficiency of the upper lip following cicatri- 
cial contraction due to a harelip operation done early in life ; in 
elderly patients a partial paralysis is found to affect one-half 
the upper and sometimes a part of the lower lip, giving to the 
mouth a drooped and grinning appearance. 

Other causes are dental defects, abnormalities of the alvelo- 
lar processes, traumatism and disease. 

In those conditions where loss of tissue is responsible for the 
defect, as in the extirpation of neoplasms, ulcerative disease 
etc., it is quite likely that cheiloplasty is required to rebuild the 
parts, but in many of these cases splendid results may be ob- 
tained by the judicious use of hydrocarbon protheses to over- 
come the usual post-operative oral distortion. It is understood 
that such injections should not be undertaken until the wounds 
are thoroughly healed and the cicatricial union fully contracted. 
This is true also in harelip operations undertaken later in life. 

The correction of labial defects coming under this method is 
not at all difficult, but artistic skill and judgment are as neces- 
sary as the surgical technic. 

The lips are plentifully supplied with blood-vessels and there- 
fore greater care in injecting a foreign mass into their structure 
is necessary, furthermore the lips cannot be placed at rest for 
any long period of time, so that the mass injected can never be 
expected to be kept in place if of a consistency hard enough to 
permit the contraction of the orbicularis muscle to move it 
about. 

From the very fact of this practically constant movement of 
a part it is self-evident such hard mass could not be retained or 
held in position for any length of time, unless the mass is small 



HYDROCARBON PROTHESES 117 

enough not to be affected by the movement and under such 
condition the correction of a defect as desired by the patient 
would require perhaps months to accomplish, owing to the very 
fact that only drop-like masses may be deposited under the skin 
in perhaps a half dozen places with the necessity of a long period 
of rest until the injections have been replaced by the new tissue 
before the next operation could be undertaken. 

It is absolutely absurd to think of injecting a lip with hard 
paraffine liquified by heat and expect to obtain a satisfactory re- 
sult. While it is true the mass is mouldable immediately after 
its introduction, so that a desired shape may be obtained, it does 
not overcome the fact, however, that the mass must harden, as 
it will, and that, while a part of it is broken away, as it were, 
from the mass proper, there is a nuclear contraction as the hard- 
ening takes place, thus overcoming partly the moulded form, 
furthermore, the movement of the parts here tends to displace 
the mass. Unequal muscular contraction breaks up not only 
the form but also the mass itself, during all of which time it is 
made to act as an irritant by virtue of the movement of the 
jmeven edges of the paraffine upon the adjacent tissue. 

Furthermore, the presence of paraffine and the resultant mass 
of new and hard connective tissue, so well recognized by all ex- 
perienced surgeons, is not desirable in the lip structure ; it 
makes the lip appear bulkly and hard and anything but natural 

It is in these very cases that the injections of cold sterile white 
vaseline is indicated. After injection the mass may be evenly 
and satisfactorily moulded out, the mass being soft and readily 
pressed into shape in the various cells of areolar tissue without 
leaving hard and uneven lumps. 

The movement of the lip is not then a source of danger in, 



n8 HYDROCARBON PROTHESES 

displacing the mass, since the acute swelling of the lip tissue 
prevents its free movement for several days, which gives the 
injected mass an opportunity to establish itself and find its 
proper place. 

Another advantage in using this preparation subcutaneously 
is that it is less irritating than hard paraffine, permits freer 
movement and creates a better production of new connective 
tissue. 

While a part of the mass may be absorbed during the replace- 
ment period the lip retains its normal consistency, and if the 
desired contour has not been attained a subsequent injection 
may be made in three weeks' time without interfering in any 
way with the former result. 

The only precaution, aside from avoiding the injection of 
blood vessels, is to keep the injection from the prolabium or 
vermilion border. The latter tissue is very prone to fatty de- 
generation or to yellowish discoloration when such a foreign 
mass has been introduced into or near its structure. 

There is no objection in injecting the lip, upper or lower, in 
several places as the cellular network about the mouth is suffi- 
ciently dense to prevent the escape of the vaseline injected from 
the adjacent opening if the distance is not less than a half inch 
between the punctures. 

The injections may be made from above downward in the 
upper lip and vice versa in the lower. They should be begun 
at the outer angle working toward the median line. 

The reaction following such an injection is usually more severe 
than in any other tissue of the face owing to the great number 
of fine blood vessels, but the swelling is readily controlled in 
two or three days by cold applications. 



HYDROCARBON PROTHESES 119 

Aristol collodion dressings over each wound suffice to close 
the punctures. 

In the median variety of defect, where a cicatricial band 
separates the lip into halves, it may be found necessary to do 
a subcutaneous dissection before a suitable injection can be 
done, but in cases of long standing the dividing wall is exceed- 
ingly thin and the thread-like adhesions below are quite easily 
broken up by the force of the injection. The later product 
of new connective tissue will tend to further improve the con- 
tour. 

Naso-labial Furrow — Unilateral and Bilateral. — This condi- 
tion in the bilateral form is exceedingly common in adults be- 
yond middle age. It is also found in those individuals suffering 
from inanition, due to whatever cause. The unilateral form is 
found principally in patients suffering from semifacial paralysis 
in which the tissue lacking the proper neurotic supply droops 
or sags down causing a deep furrow to appear from the attach- 
ment of the alae to the angle of the mouth, associated more or 
less by a flattening of the cheek contour of that side of the 
face. 

The method of correction advocated by the author varies en- 
tirely from the technic advanced by other surgeons. 

The usual method has been to introduce the needle of the 
syringe at the outer or lower extremity of the furrow and 
from one of such punctures to inject the whole line of depres- 
sion. 

While this seems right theoretically the method does not 
give the desired result. Owing to the free movement of the 
upper lip the mass, at first neatly restoring the contour, is 
crowded upward into the inferior malar region and very often 



120 HYDROCARBON PROTHESES 

downward toward the angle of the mouth where it settles in a 
hard lump which is not only obnoxious to the sight but interferes 
with the proper use of the parts concerned in mastication and 
vocalization. Invariably the operator is called upon to remove 
the disfigurement. 

It can be readily understood that hard paraffine itself, in such 
case, would prove more objectionable than a softer mass which 
upon early discovery could be moulded or massaged into better 
position while nothing less than excision would prove efficacious 
with paraffine. 

As with the lip then the author advocates the use of either 
the cold mixture of paraffine, as heretofore described, or the 
cold white vaseline according to the operator's opinion in over- 
coming the extent of the fault. For all ordinary cases white 
vaseline alone is necessary. 

The technic of injection as used by the author is as fol- 
lows :— In the ordinary case when the furrow is not too pro- 
nounced one sitting only is required. Two needle punctures 
are made above the upper line of the defect, the first being made 
about one-half inch from the wing of the nose and the other 
about one inch outward and downward. 

The needle is pushed downward under the skin until its open- 
ing corresponds to the median line or deepest part of the fur- 
row. Enough cold white vaseline is injected to bring the de- 
pressed area slightly above the plane of the skin of the upper 
lip. The second puncture is made perpendicular to the first 
and the injection made in the same manner. 

With the tip of the indicis over the first needle opening the 
mass is moulded out evenly by a gentle rocking or rubbing 
movement. The same is done with the second mass. 



HYDROCARBON PROTHESES 121 

It will be found then, that the two masses are made to meet 
at about the center of the furrow, leaving a slight wall of 
tissue between them. This wall has the virtue of preventing 
the falling down of the upper mass, at the same time divid- 
ing the quantity of the injected mass into two, and lessening 
the weight. 

If the condition is bilateral both sides are operated on at 
the same sitting. If subsequent injections are needed they are 
done three weeks later, the punctures being made between the 
former first and second punctures and the second and outer bor- 
der of the furrow. In this way the entire site is filled with a 
series of injections. 

If the surgeon desires he may increase the number of these 
needle punctures at the first sitting making them nearer to- 
gether in that event. 

It will be found necessary in some cases to inject the cold 
mixture of vaseline and paraffine into the furrow directly below 
the wing of the nose, since the integument at that point re- 
quires a mass somewhat harder than vaseline to force and hold 
it up. 

The rest of the furrow must, however, be injected with vase- 
line alone, for the reasons already given in parts that are move- 
able. 

The reaction is rarely very marked and subsides in about 
three days. 

Gentle massage may be permitted above the site of injection 
to keep the mass from crawling into the cheek. This is done 
by gently stroking the skin from below upward toward the nose 
on a line an inch above the original depression. 

The dressings are the same as before mentioned, although 



122 HYDROCARBON PROTHESES 

collodion painted over the needle openings is most serviceable 
after having sponged off the sites with absorbent cotton dipped 
into absolute alchohol to remove the vaseline that may have ex- 
uded from the openings during the moulding out process. 

Oral-Angular Furrow. — These furrows occur at the corners 
of the mouth, running downward upon the anterior chin. Small 
as these defects appear they are found difficult of obliteration, 
for the reason that the tissues are more or less under constant 
movement during the waking hours. Repeated injections, each 
of small quantity, are necessary. Hard paraffine is contraindi- 
cated. 

The injections are made from above the defect downward at 
right angles to the defect. 

It will be found difficult to keep the mass from being expelled 
on account of the movement, there being more or less oozing 
from the puncture, but if the openings can be controlled for at 
least twenty-four hours this danger may be overcome to a great 
extent. 

Ethyl chloride may be sprayed over the part immediately the 
needle is withdrawn to set the mass and followed with a drop 
of collodion. The patient is advised to keep the mouth as im- 
movable as possible for the rest of the day. 

The reaction is never severe, and is easily controlled by cold 
applications. If, after one week, there is shown a tendency to 
sagging of the mass, it should be gently massaged upward with 
the finger several times during the day for at least two weeks ; 
this will keep it in place, and allow nature to replace it with new 
connective tissue when desired. 



HYDROCARBON PROTHESES 123 

DEFORMITIES ABOUT THE CHEEKS 

DEFICIENCY OF CHEEK 

Total and Partial 

A total lack of proper contour of the cheek, generally termed 
flattening, may be due to hereditary causes, but is generally'de- 
pendent upon a cachexia due to a general disease, or fatty de- 
generation of the muscular structure of the cheeks, as found in 
those beyond middle age. *S 

A partial deficiency of the cheek or cheeks is usually heredi- 
tary but may be dependent upon digestive disorders or other 
causes of malnutrition. 

This class of deformity is found more often in women than 
men. It is usually bilateral. 

Unilateral cheek deficiency, whether partial or total may be 
congenital but is often the result of a local paralysis causing 
hemiatrophy. Traumatisms early in life or during birth and 
amputation of the inferior maxillary are other causes. 

This class of deformity is quite readily corrected by subcu- 
taneous injection, in fact it is the only known method of merit, 
superseding the former resort to partial correction by massage 
or artificial and temporary correction by the wearing of plum- 
pers in the buccal cavity. 

The method of procedure is the same in all cases, the num- 
ber of injections and quantity varying, of course, with the ex- 
tent of the defect. 

As with the rebuilding of the contour of the lips so with the 
cheeks, which must of necessity be mobile and flexible, the in- 
jection of hard parafnne is out of the question. The author 



i2 4 HYDROCARBON PROTHESES 

has observed a number of such cases and is free to say that in 
each case the result was not only abnormal in appearance, but a 
source of great annoyance to the patient. 

What is worse, is that the paraffine once injected, can never 
be removed except in places where an actual encystment has 
taken place, in which case the hard mass may be removed 
through a small incision made directly over the mass and intro- 
ducing a grooved director into the opening then by the rotation, 
or to and fro movement of which, combined with digital pressure 
the cyst is evacuated. Once the mass is replaced by a network 
of connective tissue it could not be removed except by an ex- 
tensive dissection and extirpation which leaves behind it cicatrices 
far worse than the appearance of the parts before operation. 

The author injects cold sterile white vaseline, below the skin 
here and there about the cheek at the sites of deepest defi- 
ciency. 

These injections maybe made under ethyl chloride anesthesia. 

Each injection is carried to the extent of causing a lump be- 
low the skin, the quantity being judged from a thorough experi- 
ence with similar cases. 

After the injections have all been done, the thumb of the right 
hand is passed into the mouth against the buccal mucous mem- 
brane of the left cheek and the index finger over it externally 
or on the skin surface. For the right cheek the index finger 
instead of the thumb is placed in the mouth. The mass or 
lumps are now gently pressed into the desired shape and thick- 
ness by the aid of these two fingers. A few drops of the mass 
may be forced out of the needle holes under this procedure, but 
this is of no consequence when it is considered that from one to 
two ounces may have been injected into each cheek. 



HYDROCARBON PROTHESES 125 

This gliding form of massage should be continued until the 
entire cheek presents an even and rounded out appearance. 

It will be found, in the majority of cases, that the integument 
of the cheeks about the region of the inferior border of the 
zygomatic process is rather firmly adherent and that a subsequent 
injection will be necessary to elevate the check at that point. 

Injections over the malar bone are prone to cause severe re- 
action leaving a puffed appearance just below the eyelids. This 
may be more or less permanent and is very undesirable. It 
should be avoided by injecting very small quantities at that site. 
It is always safer to add a little subsequently. 

The reaction, generally, is not severe and is readily controlled 
by cold applications, yet the author has experienced considerable 
swelling and tenderness in two cases of total cheek deficiency 
corrections which lasted for several weeks after the operation, 
giving excellent result eventually however. Such symptoms 
are dependent upon circulatory interference, but resolution 
should take place without untoward results with judicious treat- 
ment, unless the operator has been negligent by injecting one 
or more blood vessels, in which case the resultant thrombosis 
may cause breaking down of the subcutaneous tissue, abscess, 
evacuation of the mass and possibly death in part of the integu- 
ment. The precautions referred to in avoiding any such possi- 
bility have been fully given heretofore. 

Never should the operator hyperinject the cheeks, even if the 
patient insists upon looking like a puffed ball. He should be 
satisfied with a normal contour and truthfully assure the patient 
such hyperinjected contour could not be retained owing to the 
weight and dropping down of the mass before nature could 
properly replace it by organized tissue. 



126 HYDROCARBON PROTHESES 

Subsequent injections may be made about three weeks after 
the first sitting. 

With nervous and hypercritical patients the surgeon may 
elect to give the patient a number of sittings, injecting only 
small quantities at two or three places each time. This in the 
majority of cases will give better results than when an entire 
cheek is injected, for the reason that the larger mass is likely 
to be displaced by the unconscious act of the patient in sleeping 
on one or both of the rebuilt cheeks or the willful massage to 
improve the handiwork of the surgeon in their own belief. 

Massage of the cheeks after the replacement period is not to 
be tolerated. It tends to create hyperplasia by circulatory 
stimulation. 

It is not unusual to have the patient tell you that for weeks 
after the replacement period the cheeks are swollen consider- 
ably in the morning upon arising, going down gradually during 
the day. 

This is due to the spongy or loose character of the new tissue 
caused to be formed by the foreign mass which gradually takes 
on a harder and more compact form. 

The post-operative dressing will be either adhesive isinglass 
plaster or collodion. With the former, moist applications dur- 
ing the stage of reaction are not permissible. 

DEFORMITIES ABOUT THE ORBIT 

DEFICIENCY OF LID CONTOUR 

Upper and Lower Lids — Unilateral and Bilateral. — The lack 
of contour in the eyelids is not as frequently met with as redun- 
dancy of their integumentary structure ; there are cases, however, 



HYDROCARBON PROTHESES 127 

where the eyes seem to lie deep in their sockets owing to a sink- 
ing in or a collapse of the surrounding lids. 

This condition is often found to be hereditary, in other cases 
it is the result of malnutrition, a peculiar lack of adipose tissue 
about the orbit for no known reason, or fatty degeneration in 
past middle life. 

The fault is usually bilateral. In rare instances trauma about 
the orbital borders may result in lack of nutrition. Such cases 
are usually unilateral and the upper lid is affected in the major- 
ity of cases. 

The correction of these defects is found to be rather difficult 
owing to the thickness of the tissue under consideration. 

The use of hard paraffine plays havoc with eyelid tissue, ren- 
dering it hard, immobile and causing a hyperplasia of the new 
connective tissue formed thereby, as well as the peculiar yellow- 
ish pigmentary spots of irregular form resembling on casual in- 
spection xanthalasma. This discoloration has been fully de- 
scribed earlier in the work. 

The author has had occasion to remove these hard irregular 
masses investing the lower lid in several cases where paraffine 
had been injected, also two cases in which the pigmentary dis- 
coloration involved both upper and lower lids associated with 
the same hard fibrous masses. Excision under local anesthesia 
and silk suture was the method of correction employed. 

From an experience of twenty-two cases the author believes 
these conditions most amenable for correction by the injection 
of sterile oils in preference to any other substance. Even white 
vaseline does not here seem to answer the purpose, owing to its 
stimulating property of causing the resultant growth of con- 
nective tissue. 



128 HYDROCARBON PROTHESES 

While vaseline injected in the lids causes less of this new 
tissue to be formed, such tissue is never of the consistency re- 
quired. This is especially true of the upper lids. 

The oil injected, sterlized sperm oil being employed by the 
writer, is prone to absorption of more or less degree, but the re- 
sult is gratifying and lasts from six months to one year, leaving 
no untoward effect. 

If the absorption has been sufficient to leave the parts as be- 
fore the operation, a subsequent injection of the same character 
may be undertaken six months from the time of the first or even 
later as the patient may choose. 

The tissue of the eyelid is prone to swell immediately the oil 
is injected and this swelling is entirely out of proportion to the 
quantity introduced. This oedema, due to a retardation by pres- 
sure of the blood supply, is very misleading, the operator believ- 
ing the parts overinjected. A screw drop syringe is therefore 
absolutely required. 

A fine hypodermic needle is used and after a few drops of the 
foreign matter have been injected, the lid should be massaged 
gently with the tip of the indicis, employing the circular move- 
ment. 

The injection should be made at the outer end of the lid 
about one-fourth inch above or below the canthus for upper or 
lower lid respectively. 

The needle, slightly dulled, should be long enough to reach 
the full length of the part to be injected. Its course can be 
readily seen under the thin, overlying skin. 

As the injection progresses slowly and evenly the needle is 
withdrawn. 

A second puncture or injection should not be made at one 



HYDROCARBON PROTHESES 129 

sitting ; if the parts are under-injected the operation is repeated 
as soon as the swelling of the lid has subsided, which is about 
the end of the fourth or fifth day. 

The reaction, apart from the oedema, is very little, although 
there may be more or less discoloration of the parts as the re- 
sult of the obstruction offered the blood vessels. 

This is always an alarming symptom to the patient, but passes 
away completely in the usual manner in several days. 

The post-operative dressings may be collodion or silk pro- 
tective. 

Cold or hot applications, as may be best borne by the patient, 
can be used ; they tend to reduce the puffing and lessen the ec- 
chymosis. The patient should be instructed to lie with the head 
higher than usual for the first two nights to retard the oedema. 

Furrow about Canthus — Unilateral and Bilateral. — This con- 
dition is commonly called " Crow's Feet," and is, in the major- 
ity of cases, due to advancing age, but is acquired by habitually 
contracting the eyelids, as in laughing or grimacing. It is par- 
ticularly noticeable in persons employed in the drama. 

The defect is usually bilateral, but may exist at one side only 
in rare cases. 

The correction is easily accomplished by this method of sub- 
cutaneous injection, although a reduction of the furrow alone 
does not suffice, leaving a lump or elevation at the site. The 
author shades off the injection, as it were, making the site 
somewhat cone-like, the apex being at the canthus and the 
base outward toward the hair-line of the temporal region. 

Sterile oil should be injected near the canthus where the 
overlying integument is delicate. One such injection, covering 
an area of the diameter of half to three-fourths of an inch, 



i 3 o HYDROCARBON PROTHESES 

should be made and thus backed up or built outward with two 
or three injections of the white vaseline, as described under 
temporal muscular deficiency. 

The hypodermic needle should be used near the canthus, and 
the regular one over or about the temple. 

The reaction near the canthus is similar to that with lid in- 
jections. The same post-operative treatment as with the lids 
should be employed. 

Deficiency of the Ocular Stump. — It frequently happens that 
by reason of extensive inflammatory disease and adjacent adhe- 
sions of the eye, a greater part of the globe must be excised 
than in the usual case, whether the operation be an ordinary 
excision, the Mules' evisceration or the Frost modification of 
the latter. 

In such event the granular button or the stump made of 
Tenon's capsule is too small to permit of the placing and re- 
tention of the artificial eye. In other instances the stump is so 
contracted that while the artificial eye is retained it must of ne- 
cessity be allowed to rest deep in the socket, destroying the en- 
tire contour of the orbit. Again in the enucleation operation 
so little of Tenon's capsule engages the artificial eye that move- 
ment is entirely destroyed, particularly when the Mules' glass 
globe has not been introduced. 

Excellent results may be obtained in some of these cases, 
others are not amenable to the injection method because of a 
lack of sufficient stump to inject and the danger of injecting 
through the posterior wall of the capsule, the mass in part es- 
caping into the orbital apex where it is liable to impinge suffi- 
ciently upon the remains of the optic nerve to cause sympathetic 
inflammation of the normal eye. A condition at once not easily 



HYDROCARBON PROTHESES 131 

corrected, proving dangerous to the sight of the healthy eye 
and possibly producing a fatal termination. 

It is with the use of paraffine, liquified by heat and injected 
in this state, that such fatal cases as have been placed on record 
have been operated. The liquid mass under pressure forced 
into a soft pultaceous mass cannot be easily controlled, if at all, 
and accidents here are of more serious import than in any other 
part of the human anatomy, apart from the direct injection of a 
facial artery of sufficient size to produce an alarming embolism 
and death. 

The author cannot speak too forcibly against such irrational 
procedure. Other surgeons are beginning to realize the danger 
of the use of hard paraffine injections near the eye. 

The proper and safe method of improving the stump is to in- 
troduce into it, under local eucaine or cocaine anesthesia, small 
masses of the mixture of vaseline and paraffine in cold state. 
These injections into the stump and mucous membrane should 
be done several weeks apart, always keeping a respectful dis- 
tance from the remains of the optic nerve. 

The injections should be begun as near to the surface as pos- 
sible without breaking down the tissue by necrosis, keeping in 
mind that one or two of such successfully introduced masses 
will do much toward supporting the artificial eye. 

If necessary the mucous membrane back of the palpebral rim 
can be injected in like manner to give firmer hold to the eye 
and at the same time give support to the usually depressed and 
atrophied lids. 

Wet dressings are applied to allay the reactive inflammation 
which should be proportionate in severity to the amount of the 
mass injected. 



132 HYDROCARBON PROTHESES 

In three cases operated upon by the author excellent results 
were attained and no untoward results had been experienced 
two years after injection. 

DEFORMITIES ABOUT THE CHIN 

Anterior and Lateral Deficiencies 

An anterior lack of contour of the chin is generally regarded 
as of the receding type. With this is usually found a bilateral 
lack of form, especially in men. With a generally well-formed 
face such a chin gives it a weak and ofttimes a degenerate ap- 
pearance. In women a deficient chin is not as noticeable, be- 
cause of the smallness of the face in general and the predomi- 
nation of the oval type. 

The lack of prominence about the chin may be anterior only, 
the broadness being sufficient, due to a lack of development of 
the mental process, or it may be deficient laterally with a pro- 
nounced mental prominence, giving it a sharp, protruding or 
pointed appearance, or the lack of form is combined as is com- 
monly the case. 

Such chins may be made to appear normal, and even ideal, 
by the subcutaneous injection method. The type of chin most 
favored by American men is the square angular, now so plenti- 
fully seen in pen and ink illustrations. 

The tissue of the chin lends itself readily to the building-up 
process. Almost any form may be attained by the judicious 
employment of the method under consideration. 

While it is true excellent results may be obtained with hard 
paraffine, used in liquified form, it can often be shown, however, 
that the paraffine injected under pressure will run down in 




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HYDROCARBON PROTHESES 133 

narrow, pencil-like streams underneath the chin and skin of 
the anterior aspect of the neck, where they may be felt after- 
wards as hard oval cysts or of elongated form. This is not 
possible when the cold mixture of vaseline and paraffine is used, 
since the position of the mass can be easily followed with the 
eye or felt with the fingers. 

The injections should be made from either angle at the first 
sitting. Enough of the mass should be introduced to leave a 
ridge-like formation across the anterior chin, varying in thick- 
ness according to the shape of the chin previous to operation 
and the form desired. 

It is not well in chins of very deficient type to attempt to 
make the anterior contour as it should be in the first sitting. 
Too much pressure would be required, and unless the skin was 
freely movable considerable reactive inflammation would result, 
with possible necrosis of the skin in part and consequent expul- 
sion of the injected mass. 

The anterior line of such chins should be rebuilt in several 
sittings, always waiting for the parts to become normal in ap- 
pearance and sensitiveness. 

This method helps to stretch the skin, allowing of further 
injections and the introductions of a greater quantity than 
could be introduced at one time only. 

The author advocates making two or three sittings of the 
anterior restoration of contour and two for each angle. 

The angles of the chin are injected at a point about midway 
between the mental process and beginning of the external 
oblique line. The mass is injected as near the inferior ridge 
as possible, and somewhat above the attachment of the platysma 
myoides muscle. 



i 3 4 HYDROCARBON PROTHESES 

Only one needle insertion is made at each angle, and the 
mass is injected until a round elevated tumor is attained, which 
is pinched or squeezed with the fingers into the desired angular 
form, one finger being placed over the needle opening to avoid 
squeezing the mass out. 

It can be readily seen that with this putty-like mass much 
better results than with the comparatively soft vaseline could be 
obtained while with the liquified paraffine the operator would be 
at a loss to know just what had been accomplished until the mass 
had become fairly solidified and then often finding the semi- 
solid mass, which required rapid moulding to give it the desired 
shape before it would become hard and unmanageable, in a dif- 
ferent position and much more distributed than he had expected. 

For the latter reason repeated small injections have been ad- 
vised, but the author believes oft repeated injections of paraffine 
in a small area are prone to set up considerable disturbance and 
that the resultant tissue replacement is interfered with. Fur- 
thermore the injected mass would eventually be in grape-bunch 
like form and in that condition not as manageable or inducive to 
the establishment of contour angulation such as is required in 
the chin. The final appearance of chins thus rebuilt is heavy 
and rounded, lacking the concavity above the inferior prom- 
inence along the anterior line as well as the angulation laterally 

With the cold mixture advised a considerable mass may be 
injected at one sitting which is easily moulded into form and 
which retains that form unless the reactive inflammation is 
severe. This should not follow unless actual hyperinjection has 
been done or an unclean product has set up an infective cellulitis. 

When the chin is uncommonly peaked, or small, it may be 
found necessary to inject both sides of the chin beyond the angle 



HYDROCARBON PROTHESES 135 

and in an upward direction slightly below and following the ex- 
ternal oblique line. 

Such deficiency may be found decidedly unilateral as a result 
of lack of development of one-half of the lower maxillary bone, 
a resection of either maxilla for whatever cause, imperfect union 
following fracture or disease of the bone early in life. 

In such cases the lateral deficiency must be first restored, 
using the same method, before the chin proper can be built up. 
Ofttimes the lower cheek of the affected side must also be in- 
jected. This should be done after the site overlying the former 
body of the maxilla of the affected side has been rebuilt. The 
cheek should then be built out above this hard linear mass by 
the injection of cold white vaseline as heretofore referred to. 

The following illustrations show a chin deficient anteriorly 
and laterally before and the result after correction. 
f| The post-operative treatment should be collodion dressing 
followed by cold antiseptic applications for at least two days. 
The latter ameliorates the inflammation and helps to retain the 
moulded shape of the mass. Subsequent sittings may be made 
one a week or ten days apart. 

DEFORMITIES ABOUT THE EAR 

Pro-auricular Deficiency — Unilateral and Bilateral. — A deep 
furrow in front of the ear may be found unilateral in hemiatrophy 
of the face, but the condition is usually a bilateral one due to 
malnutrition or the fatty degeneration of past middle age. In 
the latter case the depression is accompanied by a redundancy 
and wrinkling of the skin. 

Owing to the close proximity of the large temporal vessels a 



136 HYDROCARBON PROTHESES 

hard mass should never be injected subcutaneously for the re- 
lief of this condition. Even the mixture of vaseline and paraf- 
fine has caused considerable reaction when injected to overlie 
these vessels. 

The author advises the injection of white sterile vaseline or 
sperm oil for this form of correction. It should be carefully in- 
jected since the vessels lie close to the skin with the anterior 
auricular crossing transversely about the center of the furrow. 

Every precaution should be taken, one injection only being 
made from below upward at each sitting if more than one is 
necessary and then only after the needle has been unscrewed 
from the syringe to make sure vessel bleeding does not follow 
the puncture. 

The reaction is usually severe with considerable oedema and 
ecchymosis. 

The resultant tissue formation likewise is active and hyper- 
plasia at this site is not uncommon, especially if the mixture or 
hard paraffine has been employed. 

A cellulitis following such an injection is exceedingly trouble- 
some, the injected mass being thrown off usually at the base of 
the furrow, which is followed by a low type of inflammation 
with a protracted oozing of serous exudate. Should such a 
case come under the care of the surgeon, thorough cleansing 
of the affected site under scrupulous antisepsis should be done 
at once, and wet antiseptic dressings be applied daily until the 
wound is entirely healed. 

A plastic skin operation must be done in most of these cases 
to overcome the ragged cicatrix formed upon healing of the 
wound. This should never be undertaken until the wound has 
been healed for several weeks at least. 



HYDROCARBON PROTHESES 137 

After the injection of the parts cold antiseptic dressings 
should be applied at once, and kept up until every sign of re- 
active inflammation has subsided. At no time should the sub- 
sequent injection be undertaken before a month has elapsed 
from the time of the former operation. 

Post-auricular Deficiency. — This defect is invariable unilate- 
ral, and then the result of a mastoid operation. 

The skin about the depressed site will be found to be more 
or less firmly adherent, necessitating subcutaneous dissection 
before an injection for correction can be undertaken. 

In this case the cold mixture of vaseline and paraffine is in- 
dicated since the softer products will hardly suffice to elevate 
the tense skin. If the former surgical operation has been done 
some time previous to the required injection the parts may at 
one or two sittings be restored to a fairly normal contour, de- 
pending entirely upon the amount of ungiving scar tissue at 
the site. If the parts are tender and not reduced to normal, 
the injections should be made frequently, about ten days apart, 
injecting a small mass across and through the subcutaneous scar 
attachment at each sitting. 

The reactions following such injections help to tease the scar 
away from the bony tissue, but should not be sufficient to cause 
extensive inflammation. 

The same mode of post-operative treatment as has been given 
with pro-auricular corrections should be followed. 



DEFORMITIES ABOUT THE SHOULDERS 

Deficiencies about the base of the neck and the shoulders are 
very commonly found in women. These defects are usually bi- 
lateral, except in rare cases. The much desired contour is 
readily restored by the subcutaneous injection method, and 
since the technic for one part is the same as for the whole 
there is no need to dilate specifically upon the treatment of 
each part. 

The author advocates the injection of cold sterile white vase- 
line only, for the restoration of the contour about the neck, an- 
terior and posterior shoulder and the mamnae, except in the 
unilateral correction of a flattening of the breast following am- 
putation for the removal of neoplasms, when the mixture of 
white vaseline and paraffine should be used, owing to the tense- 
ness of the skin following the excision of a large part of the 
integument covering the diseased gland. 

In the restoration of the contour about the neck and shoul- 
ders it is well for the surgeon to familiarize himself thoroughly 
with the superficial veins of the parts, since the vessels here are 
larger, and the introduction of foreign matter into them is lia- 
ble to lead to serious and even fatal results. 

The injections should never be made until the operator has 
assured himself of the fact that a vessel has not been entered 
into, and then only should a small quantity of the mass, i. e., 
about two or three drams, be injected at one point. 



HYDROCARBON PROTHESES 139 

The easiest mode of introducing the needle is to pinch up the 
skin between the fingers of one hand introducing the needle into 
the fold thus raised. As the mass is injected the skin should be 
raised by aid of the needle so as to allow all the immediate room 
possible for its reception. 

The mass injected is at once moulded down flat with the thumb 
or forefinger. 

A number of such injections may be made at both sides at 
the one sitting. The ethyl chloride spray may be employed 
to render the parts less painful. At no time should the entire 
shoulders be filled at one sitting for fear that the reaction may 
be severe or that for any unforseen cause infection results which 
would in such instance be indeed difficult of treatment, event- 
ually leaving the parts scarred and unsightly. 

Nor should the mass be injected intracutaneously, a fault 
sometimes observed about the base line of the neck anteriorly 
and laterally where the operator has been timid in avoiding the ex- 
terior and anterior jugular veins. Such injections invariably re- 
sult in abscess or when not extensive enough to cause necrosis 
the skin assumes a more or less permanent red or yellow discol- 
oration over the site so injected. 

The treatment for the partial or total removal of such spots 
has been referred to. 

In the average case of contour restoration of the shoulders 
about eight sittings are required, two sittings being given each 
week and as many injections made as is deemed necessary or ad- 
visable at each. 

All the precautions of technic heretofore given should be em- 
ployed. The reaction following such injections is never severe 
and little or no treatment is necessary. 



140 HYDROCARBON PROTHESES 

The needle openings are covered with aristol-collodion or the 
isinglass adhesive plaster. 

At the end of six months or more after the injected mat- 
ter has been ^quite thoroughly replaced with new connective 
tissue it is often found necessary to inject small quantities here 
and there about the shoulders owing to the contraction of the 
new tissue and its ultimate fixed disposition about the parts 
more than to the absorption of the mass injected. 

Furthermore a certain amount of oedema or swelling follows 
the injection of any foreign matter under the skin which is not, 
in cases of this kind, so readily absorbed, giving during that 
period of time a more pronounced contour or fullness, which 
passing away in the natural course of events does not imply the 
absorption of the matter injected — a statement so often made 
by those not in favor of using parafhnes of low melting points 
for subcutaneous protheses. 

Such result, however extensive, as it might be in some cases 
for the lack of proper injection or in the case with oil injections 
is at all times correctable, while the hyperplastic knobs, so often 
following the injection of parafhnes of high melting points about 
the shoulder, can only be removed by surgical means which leave 
the parts more unsightly than before anything had been done 
for the patient. 



REFERENCES 

i. Corning: N. Y. Medical Journal, Dec. 26, 1894. 

2. Gersuny: Zeitschrift fur Heilkunde, Bd. 1, Heft 9, 1900. 

3. Halban: Centralblatt fur Gynakologie, S. 134, 1901. 

4. Von Frisch: Wiener Klinische Woch., 1901. 

5. Kapsammer: " 

6. Delangre: Bull. Soc. Chir., April 8, 1903. 

7. Rohmer: Deutsche, Med. Woch., Aug. 7, 1902. 

8. Stein: " " " No. 36, 1903. 

9. Pfannenstiel: Centralblatt fiir Gynakologie, 1901, No. 2. 

10. Moszkowicz: Wiener Klinische Wochenschrift, 1901, S. 193. 

11. Eckstein: Berliner " " " S. 840. 

12. Brceckaert: Revue Hebdomadaire de Laryngologie, July 5, 1902. 

13. Baratoux: Nelaton La Rhinoplastie, Paris, p. 234, 1904. 

14. Brindel: Presse Medicate, Juin, 1902. 

15. Cheyne: Nelaton La Rhinoplastie, Paris, 1904. 

16. Downie: British Med. Jour., Nov. 8, 1902. 

17. Hill: Communication British Med. Assn., 1902. 

18. Lake: Laryngologie Soc, London, March, 1902. 

19. Spicer: Medical Record, May 17, 1902. 

20. Karewski: Centralblatt fur Chir., S. 745, 1902. 

21. Parker: Boston Med. 6^ Surg. Jour., April 17, 1902. 

22. Smith, Harmon: N. Y. Med. Jour., May 17, 1902. 

23. Hamilton: La Rhinoplastie, Paris, 1904. 

24. Quinlan: Laryngoscope, Aug., 1902. 

25. Connell: Jour. Am. Med. Assn., Sept. 13, 1903. 

26. Lynch: Virginia Semi-Monthly, Sept., 1901. 

27. Heath: American Medicine, Dec. 7, 1901. 

28. Roe: American Medical Quarterly, June, 1899. 



142 HYDROCARBON PROTHESES 

29. Eschweiler: Arch, fur Laryngologie, Bd. 17, H. 1. 

30. Connell: previous citation. 

31. Meyer: Munchener Med. Wochenschrift, No. 11, 1901. 

32. Taddei et Delaini: Rijorma Medica, Nov. 18, 20, 1902. 
^. Stubenrath: Jour. Am. Med. Assn., Sept. 19, 1903. 

34. Straume: " " " " " " " 

35. Sobieranski: " " " " " " " 

36. Dunbar: " " " " " " " 

37. Stein: Berliner Klinische Woch., S. 840, 1901. 

38. Smith: N. Y. Med. Jour., May 17, 1902. 

39. Jukuff: Arch, fur Experimentelle Pathologie, Bd. 32, S. 124= 

40. Brceckaert: previous citation. 

41. Wolff: Freie Vereinigung der Chirurgen, Berlin, Dec. 9, 1901. 

42. Eckstein: Deutsche Med. Woch., No. 32, Aug., 1902. 

43. Vassermann: Beitrage, z. Klin. Chir., Bd. 35, S. 613, 1902. 

44. Pfannenstiel: previous citation. 

45. Kapsammer: " " 

46. Leiser: Aertzlicher Verein, Hamburg, Feb. 4, 1902. 

47. Kofman: Chirurgie en russe, No. 69, 1902. 

48. Moskowicz: Wiener Klin. Woch., No. 2, 1903. 

49. Comstock: Medical Record, Nov. 1, 1902. 

50. Hurd & Holden: Medical Record, July 11, 1903. 

51. Mintz : Zentralblatt fur Chir., Jan. 7, 1905. 

52. Brceckaert: previous citation. 

53. Brindel: Presse Medicate, Juin 7, 1902. 

54. Cazeneuve: These de Paris, Oct., 1902. 
5 5 . Stein : previous citation . 

56. Freeman: See Connell, Jour. A. M. A., Sept. 26, 1903. 

57. Downie: previous citation. 

58. Alter: Medical Record, Feb. 7, 1903. 

59. Connell: previous citation. 

60. Eckstein: 

61. Paget: British Med. Jour., Sept., 1902. 

62. Smith: Jour. A. M. A., Sept. 26, 1903. 

63. Quinlan: Laryngoscope, Aug., 1902. 



HYDROCARBON PROTHESES 143 

64. Downie: previous citation. 

65. Karew ski: Berliner Klin. Woch., S. 770, 1902. 

66. Pflugh: Deutsche Med. Woch., p. 422, 1902. 

67. Cazeneuve: previous citation. 

68. Viollet: Bull, de la Soc. de Chir., Paris, 1902. 

69. DeJangre: previous citation. 

70. Ewald: Centralblatt fur Chir., S. 107 1, 1902. 

71. Moszkowicz: Wiener Klin. Woch., No. 2, 1903. 

72. Gersuny: Centralblatt fiir Gynakologie, No. 48, 1900. 

73. Eckstein: previous citation. 

74. Smith: 

75. Comstock: " 

76. Downie: " " 

77. Jukuff: " 

78. Smith: 

79. Stein: 

80. Freeman: " " 

81. Wendel: Berliner Klin. Woch., No. 41, 1903. 

82. Hertel: Grcefe Arch fur Ophalmologie, S. 239, 1903. 

83. Comstock: previous citation. 

84. Wenzel: Deutsche Med. Woch., No. 21, 1903. 

85. Eschweiler: previous citation. 

86. Morton: Am. Med., Oct. 24, 1903. 

87. Gersuny: previous citation. 

88. Moskowicz: " 

89. Parker: Boston Med. cV Surg. Jour., April 17, 1902. 

90. Freeman: previous citation. 

91. Comstock: " " 

92. Downie: " " 

93. Morton: " " 

94. Smith: 

95. Paget: " " 

96. Pfannenstiel: " " 

97. Brceckaert: ■" " 

98. Eckstein: 



144 HYDROCARBON PROTHESES 

99. Karewski: previous citation. 

100. Paget: 

101. Comstock: " " 

102. Smith: Jour. A. M. A., Sept. 26, 1903. 

IQ it it tt tt u tt tt it 

,... . it « a it a a a tt 

I04- 

105. Eckstein: " " " " " " 

106. Paget: " " " " " 

107. Hill: previous citation. 

108. Scanes Spicer: See Nelaton La Rhino plastie, p. 236, Paris, 1904. 

109. Smith: previous citation. 

no. Sebileau: Bull. Soc. de Chir., 1903. 

in. Kofman: previous citation. 

112. Tuffier: Bull. Soc. de Chir., Paris, April 6, 1903. 

113. Gersuny: Zeitschrijt fur Heilkunde, Bd. 1, Heft 9, 1900. 

114. Eckstein: previous citation. 

115. Brceckaert: 

116. Eckstein: Deutsche Med. Woch., Aug. 7, 1902. 

117. Freeman: previous citation. 

118. Downie: 

119. Smith: Med. Rev. of Rev., Nov., 1902. 

120. Mayo, Wm. J.: Jour. A.M. A., Sept. 19, 1903. 



INDEX 



INDEX 



A 

Abscess, resultant 10, 50, 57, 96 

" treatment of 58 

Absorption of parafrine. .9, 23, 32, 118 

" toxic 9 

Air embolism 9, 16 

Alae interference 23 

" injection about 23, 113 

Alcohol, use of 69 

Aldehyde, formic 11 

Alter 23 

Alum en acetate 47 

Aluminum, nasal splint 14, 98 

Amaurosis, resultant 17, 19, 131 

Amyl nitrate, use of 19 

Anaemia, local 13, 49 

Anesthetics, indication for, 8, 18, 52, 56, 

72, 76,83, 84, 107 127 

Animals, injection into 29 

Antiphlogistine, use of 47, 83, no 

Appearance, secondary mass 54 

Application of cold, 22, 44, 47, 76, 

103 122 

Aspiration of wound 59 

Asthesia of skin 43 

Auricular deficiency 80, 135 

Avoidance of hyperinjection 22 

B 

Baratoux 2 

Behavior of new tissue ^3 

Benzine solvent 15 

Bichloride of mercury, use of 69 

Blepharoplasty 88, 127 

Blindness, resultant 17, 19, 131 

Bloodvessels, compression of . . . .21, 43 
" injection into 37, 55 



Blunt needles, use of ... 21, 56, 103, 128 

Body weight, loss in 10 

Boric acid, use of 68 

Breast, injection into 30, 58 

Bright's disease, contraindication in. . 12 

Brindel 2, 20 

Broeckaert 2, n, 20, 35, 64 

C 

Canula 59 

Casts, plaster 91 

Cause of pigmentation 55 

" " redness 46 

Celloidin, use of 22 

Cellulitis 136 

Cephalagia 43 

Cheeks, deformities about 79, 123 

Cheyne 2 

Chin, deformities about 80,132 

Chloroform solvent 15 

Choice of melting point, 35, 36, 87, 88, 

92 101 

Circulation in skin 12, 44 

Classification nasal deformities, 4, 78, 90 
Cocaine, anesthetic use of, 8, 18, 72, 131 
Cold applications, 22, 44, 47, 76, 103, 

122 

" mixture, use of, 21, 22, 26, 39, 41, 
45,49,51,92 101 

" preparation 37, 39, 41 

" preparations, safety of. . . .^8, 131 

Collapse of alas 23 

" post injectio 17 

" of retinal artery 19 

Collodion, use of, 22, 25, 76, 108, 122, 

135 
Comstock 18, 29, 31, 35, 36 



148 



INDEX 



Connective tissue, appearance of . . . .54 
" " formation of . . 28, 30 

" " influenced by. .34, 38 

" " removal of 43 

Connell 2, 9, 24, 46 

Continuous current, use of 15 

Contraindication 47 

Corning 1 

Cosmolin, use of 38 

Curette, use of 52 

Current, electrical use of 27 

Cystic evacuation 29 

D 

Death by embolism 56 

Decazeneuve 20, 27 

Deficiency alar 113 

" cheek 123 

" forehead, intercilliary. . . .85 

" " lateral 84 

" inferior half , nasal 99 

" inferior third, nasal 95 

" interlobular, nasal m 

" labial 115 

" medium third, nasal .... 94 

" superior half " ....97 

" " third, " ... .92 

" total anterior " ...103 

Deficient forehead 83 

Deformities about cheeks 79 

" " chin 80, 132 

" " ears 80, 135 

" " forehead 77 

" " mouth 79, 115 

" " nose 4, 78, 90 

" " orbit 79, 126 

" shoulders. . .80, 138 

Delain 10 

Delangre 1,27 

Dense tissue, injection into 9, 12 

Depression, forehead transverse .... 82 

" linear forehead 82 

" punctate forehead 82 

Diabetes, contraindication in 12 

Diffusion, primary 9, 21,47, I0 4 

" secondary. .10, 47, 48, 50, 51 

Digitalis, use of 19 

Diminution of prothesis 32, 108 



Dissection, subcutaneous. 8, 12, 13, 52, 
75, 76, 83, 84, 94, 96, 98, 101 . . 104 

Downie 2, 22, 26, 30, 35, 64 

Drainage of wound 59 

Dressing of wounds 53, 76 

Dunbar 10 



Ears, deformities about 80, 135 

Ecchymosis 49, 97 

Eckstein. .2, 13, 25, 28, 30, 35, 36, 45, 

60 64 

Electric current, use of 27, 39, 56 

Electric paraffine heater, Kolle 40 

Electrolysis, indication for. 1 5, 40, 56, 1 1 2 

Electrolytic scarring 16, 56 

Elimination of paraffine, primary . 9, 49, 

96. - 124 

Elimination of paraffine, secondary. . 58, 

75> 96, 109 115 

Embolism, air 9, 16 

" death by 56 

" paraffine 9, 16 

" pulmonary 2, 18, 56 

Encapsulation of mass 13, 28 

Encystment of mass 13 

Epicanthus 93 

Escape of paraffine 9, 24, 29 

Eschweiler 8, 31 

Ether solvent 15 

Etherization, objection to 72 

Ethyl Chloride spray, indication for. 8, 

56, 73, 122 139 

Eucaine anesthetic . 8, 52, 72,76,83,84, 

107 131 

Evacuation of cyst 29 

Ewald 27 

Extirpation of mass . 14, 30, 43, 48, 52, 54 

F 

Facial deformities 77, 82 

Fibromatosis 50, 53 

Filling method 7 

Filling of syringe. ... 16, 25, 28, 39, 70 

Fistula, secondary 50 

Forehead, deformities about 77 

" deficiency 83 



INDEX 



149 



Forehead, depression, punctate 82 

" depression, transverse. . . .82 

" receding 83 

" " lateral 84 

Forensic notes 6 

Freeman .21, 30, 35, 64 

Frown, injection for 85 

Furrow, naso-labial 119 

Furrow, oral 122 



Gangrene. .9, 1 1, 13, 52, 57, 96, 102, 109 

Gangrenous absorption 32 

Gersuny 1, 28, 29, 32, 35, 38, 60 

" method 2 i&,33 

" " of preparing paraffine ^ 

Growth, appearance of 54 

" histological examination of 30, 

3 1 

" influences 34, 38 

" limitation 34 

" of mass 30, 34 

" removal of 43 

Guiaform, use of 11 



H 



Halban 1 

Hamilton 2 

Hart paraffine 2, 29, 45, 1 14 

" " objection to 36 

Heater, paraffine 26 

" " Kolle 39 

" " Smith 41 

" " Quinlan 27 

Heath 2 

Hertel 30 

Hill 2, 49 

Histological examination of growth 

30 31 

Holden 18 

Hook nose 99 

Hot water, use of 26 

Hurd 18 

Hyperaemia of skin 10, 44, 45, 112 

" " cause of. .46, 102 

" " treatment of . . .47 

Hyperinjection 9, 12, 14, 20, 21 



Hyperinjection avoidance of 22 

" cause of 25 

" of vaseline 15,110 

Hyperplasia of tissue. . . 10, 50, 53, 107 
Hypersensitiveness of skin 10, 42 



Ice cloths, use of .... 22, 44, 47, 76, 103 

Ichthyol, use of 47 

Idiosyncrasy of tissues 53 

Indication for injection specific 77 

Indication for protheses 2 

Infarction, pulmonary 20 

Infra orbital injection 21 

Infection 11,24 

Influence on growth 34, 38 

Injection about alae 23, 105 

chin 22 

mouth 22, 115 

nose. .24, 29,85 to 115 

neck 56 

orbit 126 

amount of. .12, 83, 84, 85, 96, 

106 109 

infra orbital 21 

into animals 2 , 

practical technic ... 73, 86, 87 

89, 104 106 

" sterile water 13, 95 

Injury with needle 25 

Immobility of skin 24 

Instruments, use for 60 

Insulation of needle 25 

" " syringe 60 

Intercilliary furrow 85 

Interference, muscular 23 

" of alar action 23 

" respiratory 23 

Intoxication, resultant 10 

Intracutaneous injection. ... 12, 18, 20 
Intraneedle solidification 25 



J 



Jukuff. 



K 

Kapsammer 1, 17 

Karewski 2, 27,35 



*5° 



INDEX 



Knife edged needles 21 

Kofman 18, 56 

Kolle elect rot hermic heater 39 

" mixture of cold paraffine 39 

" screw drop syringe 61,63 

L 

Labial deficiency 115 

Lake 2 

Lateral deficiency, forehead 84 

Leiser 17 

Linear depression, forehead 82 

Liquid paraffine, contraindication, 45, 

47 

Liquefication of paraffine 25, % s6 

Listerine, use of ■ ■ . .68 

Lobular insufficiency, nasal 108 

Local anesthesia. . .8, 18, 52, 56, 72, 76 

Local untoward results 10 

Lynch 2 

M 

Malformation, post injectio 7 

Mass, growth of . . 30, 34 

" moulding of, 24, 56, 74, 84, 87, 89, 

92, 93, 95, 96, 101, 117, 120, 

124 

Mass, removal of. 30, 43, 48, 52, 54, 

103, 108 in 

Massage, secondary 126 

Mayo 75 

Melting point, choice of, 35, 361 87, 88, 

92 101 

Melting point of cosmolin 38 

Melting point of paraffine. 10, 12, 18. 

20, 34, 45, 47, 89 in 

Melting point of vaseline 38 

Mercury, bichloride, use of 69 

Method, advantage of 8 

" filling 7 

" Gersuny 2, 8 

Meyer 10 

Mintz 19 

Mixture cold paraffine. use of, 21, 22, 

26, 39. 41, 45. 49, 51, 92, 96. . .101 
Mixture paraffine and vaseline, Kolle. . 39 
Morton 33> 35 



Moszkowicz 2, 18, 27, 35 

Mouth, deformities about 79, 115 

Movement of parts injected. . . .29, 116 

Muscles, paralysis of 19 

Muscular action, interference with . .9, 23 
Muscular deficiency, temporal 88 

N 

Nasal deficiency, alar 113 

" ant. total 103 

" inf. half 99 

" inferior third 95 

" interlobular 1 1 1 

" med. third 94 

" subseptal 114 

" sup. third 92 

deformities. 4, 78, 90 

insufficiency, lateral 105 

" lobular 108 

splint 14, 98, 102 

Xaso-labial furrow 119 

Necrosis 9, 1 1 

Needles, blunt pointed. .21, 56, 103, 128 

" infection by 24 

" injuries by 24, 86 

" insulation of 25 

" occlusion of 25 

" solidification in 26 

" use of, 21, 55, 66, 84, 86, 93, 

96, 97, 104, 105 128 

Needles, knife edged 21 

Neuroses, secondary 44 

Nose, injection about 24 

Number of sittings, 12, 55, 74, 82, 85, 
89, 94, 96, 122 139 



Occlusion of bloodvessel 103 

" of needle 25 

Ocular stump, deficiency of 130 

CEdema 11, 43, 51, 85, 128, 140 

Oil, sperm 128 

Oils, mixture of 50, 88 

Oil, subcutaneous use of. .1, 50, 88, 128 

Oral-angular furrow. . , 122 

Orbit, deformities about. . .79, 126, 125 
" venous congestion of . ... 19, 128 



INDEX 



I5 1 



Paget 26,35,36,45 

Paracentesis knife, use of 75 

Paraffine, absorption of 9, 28, 32 

" cooling of 25 

" escape of 9, 24 

" "Hart " 2, 29, 45, 114 

" heater 26, 27, 39, 41 

" Kolle 39 

" " Quinlan 26 

" " Smith 41 

" liquefication of 25, 26 

" melting points, 10, 12, 17, 18, 

20, 23, 27, 29, 30, 34, 35, 

36,41,45,47,89 in 

" mixtures... .21, 22, 41, 45, 51 

" plates, use of 109 

" screw drop syringe, Broec- 

kasrt 64 

" screw drop syringe, Dow- 

nie 64 

" screw drop syringe, Eck- 
stein 60 

" screw drop syringe, Free- 
man 64 

" screw drop syringe, Kolle 

61 63 

" screw drop syringe, Smith . . 64 

" solidification 9, 25 

" solvents 15 

" temperature of 12, 13 

Paralysis, muscular 19 

Parenchymatous injection. ...12, 18, 20 

Parker 2, 35 

Perichondritis 107 

Peripheral union 13 

Pfannenstiel 2, 17, 18, 35, 36 

Phlebitis 19, 20, ^7, 48, 56, 85, 107 

Pflugh 27 

Photography, use of 91 

Pigmentation, cause of 55 

" of skin, 10, 36, 51, 54, 

118 127 

Plaster casts, use of 91 

Plasters, use of 15, 76, 98, 108 

Post operative collapse 17 

" " reaction 9, 20, 49 



Practical technic, 72, 89, 104, 106, 118, 

l 33 

Pravaz syringe 1, 25, 60 

Precautions for injection 5 

Preparation of cold mixture, Kolle . . 39 
" " " " Smith.. 41 

" "■ instruments 70 

" " paraffine, Gersuny. . .38 

" " site 68 

Pressure necrosis. . . .9, n, 13, 62, 109 

Primary diffusion 9, 21, 47 

" elimination 9, 49, 96, 124 

Proper melting point of paraffine . . 34, 36 

Protheses diminution 32 

" indications for 2, 90 

Ptosis, resultant 87 

Pulmonary embolism. .2, 18, 19, 20, 56 

Punctate depression, forehead 82 

Puncture into vein 20 

Q 

Quantity, injection of 14, 52, 74 

Quinlan 2, 26 

Quinlan's paraffine heater 27 

R 

Rabbit, injection into 29 

Reaction 11 

" post operatio 9, 20, 49 

Receding forehead, treatment for. . .83 

Redness of skin 10, 44, 45, 1 1 2 

" " " cause of 46, 112 

" treatment for 47 

Removal of mass. . 14, 30, 43, 48, 52, 54, 

103, 108 in 

Replacement, post injectio 11 

Respiratory interference 23 

Results, untoward 9 

Resultant abscess 10, 50, 57, 96 

Retinal artery, collapse of 19 

Rhinoplasty, comparison to 90 

Roe 4 

Rohmer 1 

S 

Saddle nose 94 

Safety of cold preparations 3S 



152 



INDEX 



Scarring of skin, electrolytic. . . . 16, 56 

Schleich mixture, use of 76 

Sebileau 53 

Secondary diffusion. . .10,47, 4&, 50, 51 

" elimination 58, 75, 96, 

109 115 

" fibromatosis 50, 53 

" fistula 50 

" mass, appearance of 54 

" massage 126 

" neuroses 44 

" traumatism 58 

" treatment 93, 95 

Semisolid mixture 26 

Shoulders, deformities about. . .80, 138 
Sittings, number of. .12, 55, 74, 82, 85, 

89, 94, 96, 122 139 

Skin, asthesiaof 43 

" burning of 37 

" circulation in 12, 44, 48 

" hypersensitiveness of 10, 42 

" redness of 10, 44 

" tattooing of 57 

" yellow pigmentation, cause of. . 55 
" " " of . . . 10, 36, 

5 1 54 

Sleeve, electrothermic 27 

" insulating 26 

Sloughing of tissue . 9, 12, 13, 57, 96, 102 
Smith . 2, 10, 26, 29, 30, 35, 40, 43, 44, 45 

Snout nose 99 

Sobieranski 10 

Solidification of paraffine 9, 25 

Solvents of paraffine 15 

Specific classification for injection. . .77 

Spicer 2, 51 

Splint, nasal 14, 98, 102 

Stein 1, 10, 21, 30 

Sterilization of mass 11 

Straume 10 

Stubenrath 10 

Subcutaneous dissection. .8, 12, 13, 52, 
75> 76, 83, 84, 94, 96, 98, 101, 114 

Subinjection 9, 14, 129 

Subseptal deficiency 114 

Suppuration, secondary 50, 57 

Suture silk 8, 52, 85, 108, 114 

Syringe, Broeckaert 64 



Syringe, Downie 64 

" Eckstein 60, 64 

" filling of 16, 25, 28, 39, 70 

" Freeman 64 

" holding of 16 

Kolle.. 61,63 

" Pravaz 1, 25, 60 

" Smith 64 

Systemic untoward results 10 



Taddei 10 

Tattooing of skin 57 

Technic, practical. . . .72, 89, 104, 106, 

118 *33 

Temporal deficiency 88 

Thermophorm, sleeve 27 

Thrombosis 18, 37 

" death by 18 

Time required for development of 

new tissue 33 

Tissue, density of 12 

" growth influenced by 34 

" hyperplasia of . . .10, 50, 53, 107 

" idiosyncrasy 53 

" loss of 9 

" replacement 1 1, 34 

Traumatism, secondary 58 

Treatment for hyperplasia 47 

" " secondary abscess . . . .58 

" secondary 83, 85 

Trocar, use of 59 

Turner 58 

Tumefaction of injected site. ... 14, 50 

Tumor, electrolysis 16 

" removal of. . .14, 30, 43, 48, 52 
" secondary 43 

U 

Union, peripheral 13 

Untoward results, local 10 

9 

" " systemic 10 

Use of cold applications, 22, 44, 47, 76, 
103 122 

Use of needles, 21, 55, 66, 84, 86, 93, 
96, 97, 104, 105 128 



INDEX 



153 



v 

Vaseline, hyperinjection of 15, no 

" injection of. .1, 23, 49, 51, 89, 

109, in, 113 121 

" melting point of 38 

" mixture of 38, 49 

" retention of shape 23 

Vassermann 15 

Vein, inj ection of 20 

" occlusion of 103, 1 10 

" puncture of 20 

Venous arch, nasal 43, 85 

" congestion of orbit 19 

Viollett 27 

Von Frisch 1 



W 

Water bath, use of 12 

" sterile injection of 13, 95 

Weight, loss in body 10 

Wendel 30 

Wenzel 31 

Wound, aspiration of 59 

" drainage 59 

" dressings 53, 76 

X 

Xanthalasma 55, 127 

Xycol solvent 15 

Y 

Yellow pigmentation of skin. ... 10, 36, 
5 1 . 54 n3 



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